Laura Groshong, LICSW, Director, Policy and Practice
Margot Aronson, LICSW, Deputy Director, Policy and Practice
Texts are primarily used for social purposes: short missives conveying limited information. Much has been written about the negative impact of reliance on this mode of communication (Turkle, 2012), but the popularity of texting is obvious, particularly among those under the age of 30 who have texted regularly throughout their lives. Therefore, the increasing use of texting in the context of therapy cannot be ignored.
While there is no definitive research as yet, it appears that texting can play a useful role in some mental health treatment. Certainly for anyone who is most comfortable with texting as the preferred form of communication, this may be where a treatment relationship can best begin.
Responsibilities of the LCSW Providing Text Therapy
Clinical social workers should be knowledgeable about the promise of digital innovations in treatment, and equally about the potential downside. LCSWs choosing to engage in text therapy must be willing to explore ethical complications, perhaps even license violations, in the terms of agreement with the client and/or the texting platform.
The first issue: is text therapy really psychotherapy?
This simple definition of psychotherapy, paired with the already quoted Talkspace web advertisement, illustrate the very real differences that exist between psychotherapy and text therapy. Psychotherapy (whether in person or through synchronous videoconferencing) is a continuous process based on an established emotional relationship, an ongoing dialogue between two people in real time about complex issues with deep emotional content. Texting, on the other hand, is by its nature short, often with a gap in the timing of communications between client and therapist; it is not consistent with a dialogue based on emotional meaning, as with psychotherapy.
While texting platforms may emphasize, in the small print of the User Agreement, that the services provided are not psychotherapy, most continue to display the term “text therapy” prominently in their ads. This can create confusion for clients seeking psychotherapy and may give an appearance of misleading advertisement.
How, then, do we as LCSWs conceptualize and engage in text therapy? Perhaps “text therapy” might more accurately be called “text assessment” or “text coaching”. Texting might also be the means for starting the therapeutic process, to be converted to an in-person or videoconferencing process if it becomes an ongoing psychotherapy.
Reading any contract with care is essential, and this is most certainly true for provider contracts offered by texting platforms. Does the contract address issues such as diagnosis, HIPAA compliance, state-to-state licensing laws, and dual relationships? Does the platform set limitations on helping a client understand the differences between in-person treatment and text therapy, or on recommending in-person therapy when such treatment is indicated?
LCSW Standards of Practice
The use of ongoing asynchronous texting changes the process of therapy for LCSWs. The therapeutic alliance is significantly different when the primary means of communication is not direct ongoing communication between the client and therapist, as the asynchronous method of communication tends to preclude in depth exploration of emotional understanding. Further, a key part of psychotherapy, the “frame”, is lost if client and therapist text and reply at different times, or if the client is limited – as with some agreements - to making and receiving two texts a day to a therapist five days a week.
LCSWs base their understanding of a client on a biopsychosocial assessment, leading to a diagnosis. ASWB Technological Guidelines (2015) identifies additional factors that may contribute to determining whether a client is suitable for text therapy: age, technological skills, disabilities, language skills, cultural issues, and access to emergency services in the client’s community. How does the platform provide for assessment? Can you ensure that our standards of practice will be upheld by the texting platform?
When more intensive treatment is called for, will the platform respect and support the licensed provider’s clinical judgment? LCSWs know that a client with a psychotic disorder, an autistic spectrum disorder, or an acute episode of depression or anxiety may need in-person communication or hospitalization. Are there contractual provisions for such a situation?
Benign as texting seems, some texting platforms ask clinicians to communicate in ways that may violate state laws and regulations and/or federal laws and rules.
Most states require a clinical social worker to be licensed in both the state where the LCSW resides and the state where the client resides, if different, to provide therapeutic services. A text platform’s claim that text therapy is not psychotherapy but rather “therapeutic communication” is a blurry distinction not necessarily recognized by state social work boards. It is the LCSW’s obligation to ascertain and comply with relevant regulations of both state boards.
Licensed therapists are also responsible for making sure that the text platforms used by both client and therapist are HIPAA compliant. Further, the texts themselves are personal health information sent electronically (PHI) and must be kept private and secure. It has been reported that one text platform permitted employees – even non-clinically-trained employees – to review the content for training purposes. A Business Associate Agreement might provide a guarantee of the LCSW’s confidentiality standards, if the platform agrees to sign (HIPAA Basics for Providers, 2018, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/HIPAAPrivacyandSecurity.pdf )
Most states use the NASW and CSWA Codes of Ethics as the basis for ethical clinical social work practice. Some text platforms have contractual terms that require the therapist to meet sales targets through their text exchanges. For a clinical social worker to engage in such a dual relationship, i.e., as a corporate representative for the texting services and, at the same time, as a therapist addressing mental health problems is a clear and serious ethical violation.
Some companies use marketing techniques that also may be ethical violations. One example, potentially misleading advertising, has been mentioned. Advertising with testimonials from former clients is another. From the NASW Code of Ethics (2016)
4.07(b) Social workers should not engage in solicitation of testimonial endorsements (including solicitation of consent to use a client's prior statement as a testimonial endorsement) from current clients or from other people who, because of their particular circumstances, are vulnerable to undue influence.
Would the company agree to keep the LCSW provider from being caught up in these sorts of business-driven ethical dilemmas?
Basic to mental health treatment is thoughtful consideration of the conditions being treated and of the biopsychosocial needs of the client. The challenge for the LCSW is incorporating these basics, along with accepted standards of practice, regulatory requirements, and ethical considerations, into the texting format as contracted by the particular text platform. It is the responsibility as LCSWs to apply clinical social work standards of practice, ethics, and regulations to any work we choose to do.
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