Volume 35INumber 3IJuly 2OI3iPage$ 211-227

Text Messaging and Private Practice:

Ethical Challenges and Guidelines for
Developing Personal Best Practices
Michael E. Sude
The impact of technology on mental health practice is currently a concern in the counseling
literature, and several articles have discussed using different types of technology in practice.
In particular, many private practitioners use a cell phone for business. However, no article has
discussed ethical concerns and best practices for the use of short message service (SMS), better
known as text messaging (TM). Ethical issues that arise with TM relate to confidentiality,
documentation, counselor competence, appropriateness of use, and misinterpretation. There
are also such boundary issues to consider as multiple relationships, counselor availability, and
billing. This article addresses ethical concerns for mental health counselors who use TM in
private practice. It reviews the literature and discusses benefits, ethical concerns, and guidelines for office policies and personal best practices.

Teehnology is evolving rapidly (Haberstroh, Parr, Bradley, MorganFleming, & Gee, 2008) and ean help elinicians free up time and spaee
(MeMinn, Orton, & Woods, 2008). In partieular eounselors are using cell
phones to eonduet business (Baker & Bufka, 2011; McMinn et al., 2008)
because they provide options for communicating with clients at the clinician's convenience (McMinn et al., 2008).
Cell phones can be used to connect with clients for administrative tasks
like scheduling, cancelling, and rescheduling; to send appointment reminders; and to communicate brief thoughts or questions between face-to-faee
(FTF) meetings. Smartphones may have the ability to connect to the Internet
and interact with others in a variety of ways, but almost all cell phones at least
have a text message option.
Individuals are increasingly communicating via short message service
(SMS), better known as texting or text messaging (TM; Boschen & Casey,
2008; Militello, Kelly, & Melnyk, 2012). TM is now used clinically to provide
support or interventions for certain conditions and populations (Merz, 2010).
Text messages can include pictures, videos, and text up to 160 characters

Michael . Sude is affiliated with La Salle University and maintains a private practice in the suburbs
of Philadelphia. Correspondence about this article can be directed to Dr. Michael . Sude. La Salle
University, Psychology Department, 1900 West OIney Avenue, Philadelphia, PA, 19141. Email: sudem@
lasalle.edu.

Journal of Mental Health Counseling

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(Coss & Ferns, 2010; Merz, 2010; Militello et al., 2012). Although TM usually occurs between cell phones, messages can also be sent ftom email and
web sites (Merz, 2010). For counselors in private practice, TM is a low-cost
and convenient tool.
All forms of technology have ethical implications that raise concerns
for counselors (Baker & Bufka, 2011; Baltimore, 2000; McMinn et al., 2008;
Van Allen & Roberts, 2011; Zur, 2010). As a result, every conversation about
using technology in practice must discuss ethics and ethical decision-making
(McMinn et al., 2008). Centore and Milacci (2008), who studied distance
counseling, reported that counselors experienced decreased ability to fulfill
their ethical duties for all types of distance counseling, which underscores
the need for training on the ethical issues in using technology in practice.
Studies addressing best practices for specific types of technology (Baker &
Bufka, 2011), including TM, are lacking.
This article explores TM benefits and ethical concerns for counselors
in private practice and offers guidelines for personal best practices. It reviews
the literature on use of technology in private practice and of TM for clinical
interventions. Spcifie clinical benefits and ethical concerns are outlined.
Although they are likely to use TM to communicate with clients, because
private practitioners are not likely to have received technology training,
they have the greatest need to manage ethical risks carefully. As Bradley,
Hendricks, Lock, Whiting, and Parr (2011) said about e-mail, my purpose is
not to decide for counselors whether or not they should use TM in private
practice but rather to raise awareness of ethical concerns to help them make
more informed decisions.
RESEARCH ON USE OF TECHNOLOGY IN PRACTICE
Private Practice

McMinn, Buchanan, Ellens, and Ryan (1999) conducted one ofthe

earliest studies on use of technology in private mental health practice (N =
429). Behaviors cited most often as unethical were compromising client confidentiality by allowing others to access client information and conducting
any clinical services online or through email.
In another early study, Negretti and Wieling (2001) explored issues for
marriage and family therapists (N = 42) in terms of boundaries, being available to clients out of session, and engaging in ethical practice. Only 50% of
the clinicians then surveyed used email and only 36% cell phones, compared
to 40% who used pagers. None ofthe respondents who gave out their email
addresses reported charging for email interactions, and only 13% who used it
warned clients about confidentiality' and privacy risks.

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Recently, McMinn, Bearse, Heyne, Smithberger, and Erb (2011) examined the responses of private psychologists (N = 296) to questions about the
ethical implications of technology use, including email, cell phones, and
TM. Respondents most often reported using cell phones to provide clinical
services and store client contact information, and scheduling appointments
through email. The biggest ethical concerns were providing clinical services
via TM and email.
Perceptions of Technology Use

Centore and Milacci (2008) surveyed clinicians about how they used
different fypes of distance counseling. Online, real time text-chat was
reported by 5.6% of participants and 28.1% reported using email; of all fypes
attitudes toward text-chat were most negative, among them perceptions of
decreased abilify for counselors to build rapport with clients and decreased
abilify to assess and treat clinical issues and deal with crises.
Two studies (Haberstroh, Duffy, Evans, Cee, & Trepal, 2007; Leibert,
Archer, Munson, & York, 2006) investigated client perceptions of technology-mediated counseling. Leibert et al. (2006) found that email and instant
messaging (IM) were the most common fypes of communication reported,
and both studies reported convenience and privacy/comfort as benefits.
Participants in both reported that the lack of audio/visual cues impacted
interactions, but anonymify provided safefy for self-disclosure (Haberstroh et
al., 2007; Leibert et al., 2006).
TEXT MESSAGING AND OTHER TEXT-BASED COMMUNIGATION
Two reviews of TM in clinical practice (Militello et al., 2012; Wei,
Hollin, & Kachnowski, 2011) concluded that it may be a helpful adjunct to
FTE services; however, the limitations of the few studies make it impossible
to draw clear conclusions about its clinical effectiveness. Recent studies
were related to crisis intervention (Coss & Ferns, 2010) and eating disorders
(Bauer, Okon, Meermann, & Kordy, 2012; Shapiro etal., 2010). TM may also
help prevent relapse after termination (Aguilera & Munoz, 2011; Shapiro &
Bauer, 2010; Shapiro et al., 2010); initiate search for mental health services
(Coss & Ferns, 2010; Joyee & Weibelzahl, 2011); and help individuals pursue
outpatient services after inpatient treatment (Bauer et al., 2012).
Furber et al. (2011) studied TM between youth in treatment and therapists and discovered that most of the interaction dealt with coordinating FTF
meetings. In a small pilot study, patients in a psychotherapy group reported
that TM helped with attendance (Aguilera & Munoz, 2011). In a much
larger pilot study in the United Kingdom (UK), sending clients text messages
several days before scheduled appointments improved attendance 25-28%. If

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the rates for the clinics studied were extended to the entire UK, the annual
national savings would be close to US$250 million (Sims et al., 2012).
No other published research into individual counselors sending and
receiving text messages with clients could be found. In other words, all the
studies listed involve programmable software that manages sending text messages to certain populations or clientele at certain days and times. Gounselors
in private practice will likely not have the training or the software for that;
they will probably be sharing TM through their cell phones. More research is
therefore needed on the benefits and risks of TM interactions for counselors
in private practice.
Advantages of Text-Based Interactions

Electronic text-based interactions include TM, IM, and email, which

all have benefits for both clients and counselors. One advantage is flexibility (Shapiro et al., 2010); text-based communication may be used both
synchronously (immediate response) and asynchronously (lag time between
responses; Suler, 2000). Also, the stigma of speaking with a counselor is lessened because ofthe anonymity of text-only interactions (Gentore & Milacci,
2008; Suler, 2000), which may lead clients both to be more candid (Suler,
2000) and to experience increased ownership of the counseling process
(Gentore & Milacci, 2008). The pace and process of writing in asynchronous
interactions can, like journaling, help clients process and express thoughts
and feelings (Gentore & Milacci, 2008; Haberstroh et al., 2007; Suler,
2000). Some clients may express themselves better in writing (Suler, 2000),
and text-based counseling helps clients feel less pressure about disclosing
(Haberstroh et al., 2007; Suler, 2000).
Beyond the clinical benefits, cell phones are so common that they
attract little attention from others, so individuals can use them with little fear
of social stigma (Boschen, 2009; Gentore & Milacci, 2008). TM, in particular, is widely available (Militello et al., 2012) because it costs little (Aguilera
& Muoz, 2011; Boschen, 2009; Boschen & Gasey, 2008; Shapiro et al.,
2010) and does not require a smartphone (Aguilera & Muoz, 2011). TM is
also convenient (Goss & Ferns, 2010; Shapiro et al., 2010); is accessible at
any time (Boschen, 2009; Gentore & Milacci, 2008; Militello et al., 2012;
Shapiro et al., 2010); and offers privacy and anonymity (Goss & Ferns, 2010).
Individuals who are highly sensitive to others' perceptions or reactions may
prefer a method of communicating that feels safer (Gentore & Milacci, 2008;
Haberstroh et al., 2008; Leibert et al., 2006).
For counselors, text-based interactions are easily documented (Suler,
2000). Haberstroh et al. (2008) reported among the clinical advantages the
ability to review the transcript ofthe interactions during the session to clarify

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previous wording, and the slower pace allowing more time to reflect on the
clinician's own responses.
TM also offers the ability to have regular contact between sessions
(Aguilera & Muoz, 2011) and to remind clients of skills learned ETE to
help prevent relapse between meetings (Boschen, 2009). Eor administrative
tasks like scheduling, cancelling, or rescheduling appointments and sending
billing or appointment reminders, TM can save private counselors time
beeause it can be read and responded to asynchronously (Boschen, 2009;
Sims e t a l , 2012).
Eor some elients TM can also serve as a transitional object or a tangible
way to remain connected to the counselor (Neimark, 2009). TM may help
elients through the times between therapy sessions, much like ealling a
eounselor's voice mail and leaving messages that do not need to be returned
(Gutheil & Simon, 2005). Texts from counselors to clients also serve as
transitional objects, similar to the letter-writing common in narrative therapy
(Winek, 2010).
In family counseling, TM can help family members who struggle to
interact with eaeh other in real time. Asynchronous TM allows them to take
time to make meaning of messages received and to formulate responses that
can be edited before being sent. The counselor can be eopied on messages
between family members so that there is no eonfusion about the words eommunieated, and so that there is a monitor of the communication. Koocher
(2009) described using email with separated or divorced parents to communicate about visitation schedules and other parenting issues.
TM has also been cited as a particularly helpful adjunct for GognitiveBehavioral Therapy (GBT; Boschen, 2009; Boschen & Gasey, 2008; Shapiro
& Bauer, 2010). It can be used for self-monitoring (Boschen & Gasey, 2008;
Shapiro & Bauer, 2010) and to report on or complete homework (Boschen,
2009; Boschen & Gasey, 2008; Shapiro & Bauer, 2010). TM lessens the
possible shame of carrying around paper and pen and allows clients to
send counselors information and reeeive feedback more quickly (Shapiro
et al., 2010). TM time and date stamping helps keep the information being
exchanged more accurate than is possible with journals (Shapiro & Bauer,
2010). Messages can be sent at set times and can be helpful when ETE or
phone contact is not possible or appropriate. Asked by TM for information,
counselors can respond immediately, respond later, and store communications electronically (Boschen & Gasey, 2008). Einally, as distance counseling, TM is an option for clients who live in rural areas or cannot leave home
because of disability or illness (Gentore & Milacci, 2008).

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Limitations of Text-Based Interactions

One limitation is the lack of a sense of therapeutic presence (McAdams

& Wyatt, 2010; Suler, 2000)clients may have difficulty feeling connected
to counselors because there are no audio or visual cues (Centore & Milaeci,
2008; Haberstroh et al., 2007; Haberstroh et al., 2008; Siiler, 2000). They
may also feel less understood, less cared for, and less safe (Centore & Milaeci,
2008). Text-based interactions may also lack spontaneity (Suler, 2000), and
the slower pace eould limit disclosure (Haberstroh et al., 2007).
Another limitation can be the technology itself (Haberstroh et al.,
2007; Haberstroh et al., 2008). TM technology can fail, so that messages are
never sent or received (Shapiro & Bauer, 2010). Also, some clients may not
know how to use cell phones or be able to read messages because of limited
eyesight, and some may be unable to afford TM (Aguilera & Muoz, 2011;
Shapiro & Bauer, 2010).
The main limitations of TM interactions are the ethical concerns they
raise and the lack of regulations and ethical guidelines for best practices.
Wliat follows addresses the guidelines that do exist and then explores specific
issues that are important for counselors to consider if they choose to use TM
in private practice. The last section suggests best practices for each of the
ethical concerns raised.
Ethical and Regulatory Guidelines

Technology evolves so quickly that state regulatory boards and professional organizations may never be able to provide guidance for using specific
types in practice (McAdams & Wyatt, 2010; McMinn etal., 2008; Nicholson,
2011; Van Allen & Roberts, 2011). However, some state boards and professional organizations do provide general guidance for doing so (Baker &
Bufka, 2011; McAdams & Wyatt, 2010).
Bradley etal. (2011) noted that the American Mental Health Counselors
Association (AMHCA) Code of Ethics (2010) is current on providing guidance for the use of technology. The seetion dedicated to technology-assisted
counseling provides guidelines for preserving confidentiality when transmitting and storing information electronically. The AMHCA has also published
a white paper (2012) as a companion to the Code of Ethics (2010) that makes
recommendations for technology-assisted counseling. The white paper
recommends, for instance, that counselors be "technologically savvy in the
modality of communication being used," plan for crises and use with at-risk
clients, and encrypt all text-based communication.
The American Counseling Association (ACA) Code of Ethics (2005)
also has guidelines for counselors using technology in practice. It addresses
confidentiality, encryption, counselor competence, appropriateness for treat-

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ment, emergency protocols, expectations of responses, and billing policies

(Bradley et al., 2011; Trepal, Heberstroh, Duffey, & Evans, 2007).
Furthermore, as of mid- to late-2008, 14 state boards had issued regulations for technology-assisted counseling, and 20 more were drafting or
discussing such regulations (McAdams & Wyatt, 2010). Ten states have prohibited technology use, and many boards have supported it conditioned on
special circumstances (McAdams & Wyatt, 2010).
ETHICAL CONCERNS FOR PRIVATE COUNSELORS
Although counselors can currently use several types of technology
in practice, many have little understanding of the associated ethical risks
(McAdams & Wyatt, 2010). For eounselors using TM as an adjunct to FTF
services, ethical concerns include confldentialify, documentation, counselor
competence, appropriateness of use, and misinterpretation. Boundary issues
to consider include multiple relationships, counselor availability, and billing.
Confidentiality
The primary ethieal concern for counselors who use TM is information security (Bosehen & Casey, 2008; Merz, 2010) because ofthe risk of
violating client eonfidentialify (Bradley et al., 2011; Furber et al, 2011; Zur,
2010). Among TM identifleation problems are not knowing whether a elient
is alone when receiving a text, whether the client is actually the one texting,
and whether someone else has access to the client phone and saved conversations (Suler, 2000). Like email (Barnett & Scheetz, 2003), text messages
are more like postcards than private letters and, like voice mail, clients may
assume that only counselors can access them (McMinn et al., 1999). Also
like email (Cutheil & Simon, 2005; Van Allen & Roberts, 2011), they can
accidently be sent to the wrong person.
Portable electronics and the information stored on them can be easily
lost or stolen (Van Allen & Roberts, 2011; Zur & Barnett, 2008), and even the
digital contact list on a counselor's cell phone can compromise eonfidentialify. Finally, keeping information confidential is not completely in the control
ofthe phone owner (Van Allen & Roberts, 2011). For example, counselors
need to consider the risk to confldentialify if TM is intercepted by hackers
(Merz, 2010).
Documentation
Besides protecting the information exchanged, counselors need to
know how to securely document and store text messages. McMinn et al.
(2008) questioned what constitutes secure password protection or encryption
for electronic records storage and transfer, and what can be done to ensure

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that confidential information cannot be retrieved when electronic devices

are disposed of. As clinical contacts (Zur, 2010), like e-mail (Bradley &
Hendricks, 2009; Gutheil & Simon, 2005; Zur, 2008, 2010), text messages
can be subpoenaed as part ofa client's file. Providers also must be prepared
for technology "death" and have secure backup services and a protocol for
disposing of dead technology (McMinn et al., 1999).
The counselor must give precedence to the client's rights to privacy and
confidentiality over any personal convenience (Nicholson, 2011), and how to
do this for TM is not clear. For example, email should be printed and placed
with notes, but it is more like a transcript than a session summary (Gutheil
& Simon, 2005). TM is a transcript of interaction as well, but may have less
information because of the character limits.
Counselor Competence, Appropriateness, and Misinterpretation
Beyond confidentiality, there are ethical concerns related to counselor
competence, the appropriateness of using TM, and misinterpretation of
interactions. Gounselors are rarely prepared or trained to use technology
properly within professional relationships (Neimark, 2009; Van Allen &
Roberts, 2011). For instance, as Haberstroh et al. (2008) noted for online
counseling, TM leaves open the possibility of interacting with several clients
at the same time, which can lead to distractions and mistakes.
Once counselors are trained to use TM, they will need to decide
what types of interactions to use it for. TM can be a quick way to contact
counselors in crisis situations, any day or time, but Haberstroh et al. (2008)
reported on situations when text-based interactions may not be appropriate,
and self-harm was one. There are also practical barriers to the use of TM in
emergencies. Gounselors may not receive messages immediately or be able to
reach clients in crisis (Shapiro & Bauer, 2010), and neither party may know
whether messages were received. In short, counselors must determine when
and how it is appropriate to use TM with clients.
There is also a higher chance of misinterpretation, misunderstandings,
and confusion in text-based communication, especially with culture-specific
language and a lack of audio or visual cues (Baltimore, 2000; Barnett &
Scheetz, 2003; Koocher, 2009). Glient difficulties with expressing themselves
in writing (Suler, 2000) may be magnified in TM because it is so hard to
explain something lengthy or complex in a limited space (Shapiro & Bauer,
2010). Moreover, the lack of audio or visual cues may limit ability to make
meaning of interactions, so counselors must be able to tolerate ambiguity
(Trepal et al., 2007) and check out assumptions.

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Boundary Concerns

One possibility for misinterpretation is the counseling relationship

being interpreted differently. Counselors must be careful to avoid treating
electronic communication with clients as off the record or casual. The possibility that casual or informal interactions might lead to boundary confusion
for clients has been explored for email (Bradley et al., 2011; Cutheil &
Simon, 2005), and the risk is higher with TM because it is less common in
professional relationships. Counselors may also reeeive inappropriate messages from clients by mistake, or because TM is disinhibiting (Suler, 2000).
Furthermore, interactions through TM can be time-consuming, and
there is less time for actual exchange than in the same amount of FTF time
(Trepal et al, 2007). This is a consideration for billing: Should TM be billed
per text? per minute? or how? (Zur, 2008).
Cutheil and Simon (2005) raised concerns about billing for email interactions with clients. If email contact is not billed, clients could interpret it as
social interaction. Failure to bill for clinical emails could also lead to issues
of countertransferenee if counselors come to feel resentful. Furthermore,
counselors who fail to bill for email contact could be unknowingly colluding with clients to extend sessions. For example, many emails, ranging from
long stories to seemingly easy questions expressed in one sentence, can take
a great deal of time to read and respond to (Cutheil & Simon, 2005; Zur,
2008). This can fit for TM as well, because one limitation of asynchronous
communication is boundary confusion around appointments (Suler, 2000).
Time spent communicating with clients through asynchronous communication must be established by counselors (Bradley & Hendricks, 2009; Bradley
et al, 2011; Negretti & Wieling, 2001; Shapiro & Bauer, 2010; Zur, 2008) in
order to model self-care and boundaries. Counselors will need to determine
personal best practices based on how they feel about being available outside
of session.
CUIDELINES FOR PERSONAL BEST PRACTICES
Van Allen and Roberts (2011) stated that newer generations of mental
health professionals, who have grown up with modern technology, often
are naive about its privacy, security, and professional implications. In other
words, familiarity with technology does not mean that counselors know how
to avoid professional problems. Clinicians tend to use new forms of technology in practice before fully understanding the risks. They do not need to
become experts but should understand the technology they are using, weigh
risks as well as benefits, and make decisions in terms of upholding ethical
codes and regulationsthe ethical responsibility always lies with the professional (McAdams & Wyatt, 2010; Nicholson, 2011; Van Allen & Roberts,

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2011). The following section addresses specific issues already raised, but first
addressed are general recommendations for private counselors who use TM.
The basic decision private counselors must make is whether or not to
use separate cell phones for their business and personal hves. For counselors in full-time private practice, a separate business phone may make sense
because of the volume of contacts. Part-time counselors may choose to use
their personal cell phone to conduct business, designate their voice mails
"confidential," and provide emergency contacts for clients in crisis. However,
it is recommended that counselors not use personal cell phones for clinical
practice in order to protect the data exchanged, the therapist's privacy, and
clinical boundaries (Shapiro & Bauer, 2010).
After securing a separate business cell phone, counselors should find
out what technology-assisted services are covered by their hability insurance
before using the phone as an adjunct to FTF practice (Baker & Bufka, 2011;
Bradley & Hendrieks, 2009; Bradley et al., 2011). This is vital. Counselors
working in agencies often have guidelines for how they can and cannot interact with clients, but private counselors decide for themselves.
If covered by liability insurance, the third step is for counselors to write
up consent policies addressing technology-assisted services (Baker & Bufka,
2011; Barnett & Scheetz, 2003; Bradley & Hendrieks, 2009; Bradley et al.,
2011; Merz, 2010; Negretti & Wieling, 2001; Trepal etal., 2007; Van Allen
& Roberts, 2011; Zur, 2008, 2010; Zur & Barnett, 2008). Signed client
informed consent is one ofthe clearest ways to manage risk and limit liability, and it allows clients to make informed choices about clinical services.
The policies should be reviewed in a conversation at the start of services
and periodically thereafter (Barnett & Scheetz, 2003; Bradley & Hendrieks,
2009; Bradley et al., 2011; Merz, 2010; Trepal et al., 2007; Zur, 2008; Zur &
Barnett, 2008). Each counselor must decide what the policies should cover.
Most state boards agree that the policies should inform clients of what
can be expected in terms of technology-assisted services (McAdams & Wyatt,
2010). Policies should address confidentiality (Baltimore, 2000; Barnett &
Scheetz, 2003; McAdams & Wyatt, 2010; Trepal et al., 2007; Zur, 2008,
2010); security measures to protect electronic information (Zur, 2010; Zur &
Barnett, 2008); how to handle emergencies (Bradley et al., 2011; McAdams
& Wyatt, 2010; Zur, 2008); what is appropriate to send to a counselor
electronically (Baltimore, 2000; Bradley & Hendrieks, 2009; Zur, 2008);
appropriate times and ways to contact the therapist out of session (Negretti &
Wieling, 2001); the times and frequencies when the therapist will communicate out of session (Bradley & Hendrieks, 2009; Bradley et al., 2011; Negretti
& Wieling, 2001; Zur, 2008); and fees or billing policies for non-FTF contact
(Bradley et al., 2011; Negretti & Wieling, 2001; Zur, 2008). The following

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subsections explore guidelines for drafting personal best practices for these
specific ethical issues.
Confidentiality
As with email (Bradley et al, 2011), counselors must inform clients that
third parties may be able to access electronic interactions. Private counselors
can do several things to help protect the information transmitted and stored
on cell phones. Zur and Barnett (2008) provided practical recommendations
for protecting portable electronic devices, sueh as removing unnecessary files
when traveling, never leaving deviees unattended, and never letting anyone
borrow them.
The SIM card in cell phones stores text messages, so password security
for cell phones is also recommended. Furthermore, eounselors should send
and read text messages in private; eell phones should have spyware and
antivirus software to help ensure privaey (Merz, 2010); and settings should
be adjusted so that messages do not appear when the phone is locked. On
some cell phones counselors and elients can also set an option to send
"read receipts" that will help both parties know whether text messages were
received.
The use of a secure server and software that manages the texting is recommended (Shapiro & Bauer, 2010), and any digitally stored information
on portable devices should be without identifiable confidential information
(Nieholson, 2011). Although it would be more convenient for counselors to
store contacts by full names, it is recommended that they use only initials.
Furthermore, passwords for files are insufficient; counselors should learn
to code or enerypt confidential data stored on portable electronic devices
(Boschen & Casey, 2008; Nicholson, 2011) and transmitted electronically
(Trepal et al, 2007).
Counselors can encrypt messages using technology from cellular serviee
providers or using third parties (Merz, 2010). For smartphone owners, apps
offer options. Both sender and receiver may need the apps to decrypt messages, or only messages already sent or reeeived (stored) may be enerypted,
leaving them unprotected during transmission.
Confirming identity in each contact is also important (Baltimore, 2000;
Barnett & Scheetz, 2003). There is no clear way to do this securely, but one
option is for clients to use a code word to identify themselves. Another is for
clients to begin eaeh TM interaction by answering a question agreed upon
at the start of services. As a general rule, a eounselor communicating with
clients through TM should pay close attention to the client's language to
see if it is aligned with previous TM interactions. Counselors should also be
vigilant to double-check who the message is being sent to in order to avoid
accidentally breaking confidentiality (Van Allen & Roberts, 2011).

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Documentation
Counselors also need to decide how to store and document text messages after transmission. Text messages, like voice messages and emails, are
clinical contacts (Zur, 2010). In order to limit the information stored on
highly portable cell phones, counselors may wish to transfer stored information. Archiving text messages involves either forwarding them to email to be
saved or printed, taking screen shots of them with a smartphone and then
sending them to email, or using third-party services to archive them (Zur,
2010).
There must also be a plan for disposal of cell phones used for therapy that
is communicated to clients (Bosehen, 2009). When disposing of cell phones,
counselors should wipe the data from the devices by resetting or reformatting
them (Barnett & Scheetz, 2003; Merz, 2010). Cell phone manufacturers can
explain how counselors can erase or reformat their cell phones.
Counselor Competence, Appropriateness, and Misinterpretation
Counselors must consider their comfort level, competence with technology, and knowledge of TM before using it in practice (Bradley et al.,
2011; Merz, 2010). They will need to determine how TM will be used with
each client (administrative tasks, support, intervention, etc.), and regularly
evaluate its helpfulness (Merz, 2010). They should be trained before using
any type of TM software, take time to learn to use the programs properly, and
be able to troubleshoot problems (Baker & Bufka, 2011; Bradley et al., 2011;
Merz, 2010; Shapiro & Bauer, 2010). Counselors interacting with clients
through TM from home should have a designated space, sueh as a home
office, to limit distractions and keep interactions professional (Haberstroh et
al., 2008).
For some clients, TM may not be appropriate or helpful (Shapiro &
Bauer, 2010). Counselors must assess whether each client can use the technology effectively (Bradley et al., 2011). Just as counselors must be familiar
with the technology used in practice (Negretti & Wieling, 2001), so must clients. This would include how often elients use TM in daily life, how familiar
they are with common TM emoticons and acronyms, whether or not they
can afford the service, and whether they have reading or eyesight limitations.
If counselors determine that a client is competent with TM, they can
have a conversation to decide if the client would consider TM as an adjunct
to FTF treatment (Bosehen, 2009). In these conversations counselors need
to address handling clinical emergencies, such as self-harm, and discuss
emergencies, including having another way to contact the client, and another
contact person for the client in case of emergency (Shapiro & Bauer, 2010).
Counselors should also be aware of different ways messages might be
interpreted, and discuss with clients at the start of services a protocol for

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handling misinterpretation (Shapiro & Bauer, 2010). They need to attend to

both TM content and process, be sensitive to cultural issues and stereofypes
(Trepal et al, 2007), and be able to process TM interactions in FTF sessions
(Neimark, 2009).
To help limit misinterpretation, both parties may add visual cues
through in-text graphics, spacing, punctuation, and use of caps (Suler, 2000).
Counselors also need to become familiar with common acronyms used in
text-based communication, such as, "LOL (laugh out loud), ROTFL (rolling
on the floor laughing), AFK (away from keyboard)," and the use of emoticons or characters to convey emotions (i.e., :-( - sad or annoyed; :) - happy;
"(::( )::) = a band-aid used to represent help)" (Trepal et al, 2007, p. 272).
Counselors can also write out their own reactions and nonverbal responses
(i.e., s m i l i n g , l a u g h i n g , etc.; Haberstroh et al, 2008; Trepal et
a l , 2007).
Boundary Concerns
When using TM in practice, particular attention should be paid to its
tone and the professional language. This is difficult because the TM interaction is designed to be concise. Counselors should reread text messages
before they hit "send," asking themselves whether they would say it the same
way in an FTF session. If not, language or tone must be changed (Cutheil
& Simon, 2005).
Counselors who receive text messages from clients that they interpret
as out of character or unprofessional should address their concerns with
clients in therapeutic, nonconfrontational ways (Cutheil & Simon, 2005).
Neimark (2009) depicted a scenario in which a client texts a clinician to say
that the previous session was "useless," and the clinician is unsure whether or
how to respond. Counselors should discuss with clients what information is
appropriate to exchange through TM (Shapiro & Bauer, 2010). A counselor
who believes that a message received was inappropriate can respond therapeutically by describing her or his own experience of the message, asking
about the client's intentions, not pathologizing the interaction, and giving
precedence to the client's needs.
To avoid feeling on call, counselors should also decide how much time
they will be available through TM and communicate the decision to clients
(Koocher, 2009; Shapiro & Bauer, 2010). As with any other technological
adjunct, there must be clear agreement on TM boundaries and billing policies (Boschen, 2009; Shapiro & Bauer, 2010). One option is for clients to be
able to send messages any time, and for counselors to respond at predetermined times (Shapiro & Bauer, 2010). Similarly, Bradley et al. (2011) suggested setting a time of day to check and return emails and setting boundaries

223

around when they are not checked or returned, such as nights and weekends.
Presented in this way, it is made clear that TM is asynchronous only.
Gounselors must also decide how to bill for TM because in private practice time is money. Haberstroh et al. (2008) reported that the slower pace of
text-based sessions meant that less material was covered than in FTF settings,
even though counselors may spend a great deal of time responding to short
TM messages or questions.
It is recommended that private counselors who agree to TM interactions
beyond administrative tasks make clear the fee for reading and sending each
message. For some TM plans, customers are charged per message or given
a limited number of monthly messages. Gharging per message read and
received is in line with many cell phone contracts, and is a more concrete
way for counselors to set boundaries than recording time spent reading, formulating, and responding to text messages. The private counselor thus has
the option to set boundaries around the time and energy spent on these tasks,
knowing it will be compensated.
Training

It appears that no study has yet looked at ways graduate training programs
address or fail to address the ethical risks of using TM in practice. However,
several articles have called for graduate ethics courses to address issues of
professionalism when posting on and searching the Internet (Lehavot, 2009;
Myers, Endres, Ruddy, & Zelikovsky, 2012; Van Allen & Roberts, 2011).
The consensus is that because they are the best way to address ethical uses
of technology, vignettes summarizing risks and benefits of TM use should be
incorporated into graduate ethics courses. Finally, the benefits and risks of
using many forms of technology should be addressed as needed in clinical
supervision and through professional development activities (Lehavot, 2009;
Lehavot, Barnett, & Powers, 2010; Myers et al., 2012) for both graduate students and working professionals.
CONCLUSION
Technology-based counseling services will continue to grow (Gentore
& Milacci, 2008; Haberstroh et al., 2007; McAdams & Wyatt, 2010). Rather
than closing off to new technology, it may be more effective for mental
health counselors to learn about the benefits, risks, and ethical issues related
to using it in practice (Barnett & Scheetz, 2003). TM is possibly the most
inexpensive and widely available technology that can impact mental health
treatment (Aguilera & Muoz, 2011). It is expected to become more popular
because of its advantages as a tool for contact between sessions, so counselors
may need to embrace it to some degree (Merz, 2010). Distance counseling,

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Text Messaging and Private Practice

including TM, is also likely to continue to grow because it lowers overhead

eosts and also offers counseling options for clients who cannot access ETE
services because of where they live or their health problems (Gentore &
Milacci, 2008). Glinicians need to inform colleagues through professional
publieations of the benefits and challenges of using technology so that best
practices can be formulated (MeAdams & Wyatt, 2010). Eor private mental
health counselors using TM, this is a beginning.
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