Text-Based Communication in Telemental Health
Knowing and Minimizing the Risks
With the increase in the use of technology to provide mental health services, so too have there been increases in the risks that come with providing a virtual care practice. One risk that merits discussion is the use of text-based communications. Depending on your carrier settings and mobile device properties, the text messages stored on and sent from your device may possibly be unencrypted and vulnerable to security threats. Any text-based communications you have with a child or adolescent pose other unique risks in that parents typically have a legal right to view their children’s medical records. Remember that text messages are a literal transcript of communication between you and your clients. When texting is used therapeutically, it is considered protected health information (PHI), and you must take steps to protect it.
I remember when I first started using text messages. At that time, there were no laws, rules, or codes written about the use of texting for clinical purposes. The need to encrypt messages had not been discussed because, as clinicians, we were not using this method to communicate with clients yet. During this time, one of my first clients asked me if she could use texts to schedule an extra appointment, and I agreed that she could. A few weeks later, I received a text from her saying she was feeling emotional and needed a session that day. I was teaching all day, so on my break, I let her know that I did not have an appointment open and that I would see her in two days at her scheduled session.
About an hour later, she sent a text back asking me to cancel her appointment. I knew right away that she was upset because she never canceled appointments. During my next break, I immediately texted her back and said, “As requested, I canceled your appointment. I hope you call and reschedule soon, and I hope you are okay.” She then texted back a paragraph on how she was upset at my “coldness” and how I stopped caring about her. This communication was not cold and uncaring to me, but it was to her, and her experience is what mattered to me. I called her and scheduled a new appointment in two weeks to talk about this.
In this situation, there are several questions to consider:
To answer the first question of who was at fault: It was me. Using text messaging with this client caused harm. Although it was not intentional, it did happen, and I could have avoided it. It is easy for clients to feel misunderstood when using text messaging and emails because they are unable to hear the clinician’s caring tone or see the warm expressions and body language that show interest. This happens so much with text messaging and emails that the code of ethics now addresses it. The code of ethics clearly states that we must discuss miscommunications before using these types of asynchronous communications with our clients.
This dear client returned in two weeks and flopped down in the chair while asking me why I did not want to see her anymore. She also wanted to know why I thought she would not get any better. I definitely used this as a therapeutic moment to help her understand how this thinking pattern was part of her other important relationships. But I first apologized for the harm and the hurt she experienced, and I explained that we needed to have an important discussion about the possibility of misunderstandings and miscommunications going forward. She left feeling healed from the pain she experienced and with new ways of looking at her thinking. She also left with a refreshed understanding of my care and concern for her.
However, it is not just text messages that can pose risks, as harm can also occur with emails. Specific areas of concern include data leakage, platform-specific issues, and back-end servers. Like text messages, email messages are also unsecured and can be accessed by third parties. Even deleted emails may be preserved by other third parties, such as internet service providers. When a professional sends an email from an encrypted email service, there is also no guarantee that the message is safe where it has been sent.
Although a complete and thorough discussion of the broad set of security issues related to the use of mobile devices in the healthcare environment is beyond the scope of this post, you can find information regarding how to minimize these risks in my new book, Telemental Health: The Essential Guide to Providing Successful Online Therapy.
*This is an excerpt from Telemental Health by Joni Gilbertson. Copyright © 2020, Joni Gilbertson. PESI Publishing & Media
I remember when I first started using text messages. At that time, there were no laws, rules, or codes written about the use of texting for clinical purposes. The need to encrypt messages had not been discussed because, as clinicians, we were not using this method to communicate with clients yet. During this time, one of my first clients asked me if she could use texts to schedule an extra appointment, and I agreed that she could. A few weeks later, I received a text from her saying she was feeling emotional and needed a session that day. I was teaching all day, so on my break, I let her know that I did not have an appointment open and that I would see her in two days at her scheduled session.
About an hour later, she sent a text back asking me to cancel her appointment. I knew right away that she was upset because she never canceled appointments. During my next break, I immediately texted her back and said, “As requested, I canceled your appointment. I hope you call and reschedule soon, and I hope you are okay.” She then texted back a paragraph on how she was upset at my “coldness” and how I stopped caring about her. This communication was not cold and uncaring to me, but it was to her, and her experience is what mattered to me. I called her and scheduled a new appointment in two weeks to talk about this.
In this situation, there are several questions to consider:
- Who bears the burden of the harm caused here?
- What issues do you see with using text messaging?
- What could have been done differently?
To answer the first question of who was at fault: It was me. Using text messaging with this client caused harm. Although it was not intentional, it did happen, and I could have avoided it. It is easy for clients to feel misunderstood when using text messaging and emails because they are unable to hear the clinician’s caring tone or see the warm expressions and body language that show interest. This happens so much with text messaging and emails that the code of ethics now addresses it. The code of ethics clearly states that we must discuss miscommunications before using these types of asynchronous communications with our clients.
This dear client returned in two weeks and flopped down in the chair while asking me why I did not want to see her anymore. She also wanted to know why I thought she would not get any better. I definitely used this as a therapeutic moment to help her understand how this thinking pattern was part of her other important relationships. But I first apologized for the harm and the hurt she experienced, and I explained that we needed to have an important discussion about the possibility of misunderstandings and miscommunications going forward. She left feeling healed from the pain she experienced and with new ways of looking at her thinking. She also left with a refreshed understanding of my care and concern for her.
However, it is not just text messages that can pose risks, as harm can also occur with emails. Specific areas of concern include data leakage, platform-specific issues, and back-end servers. Like text messages, email messages are also unsecured and can be accessed by third parties. Even deleted emails may be preserved by other third parties, such as internet service providers. When a professional sends an email from an encrypted email service, there is also no guarantee that the message is safe where it has been sent.
Although a complete and thorough discussion of the broad set of security issues related to the use of mobile devices in the healthcare environment is beyond the scope of this post, you can find information regarding how to minimize these risks in my new book, Telemental Health: The Essential Guide to Providing Successful Online Therapy.
*This is an excerpt from Telemental Health by Joni Gilbertson. Copyright © 2020, Joni Gilbertson. PESI Publishing & Media
Virtual care is the new normal. Are you prepared?
In this comprehensive guide, therapist and certified telemental health trainer Joni Gilbertson discusses the entire virtual treatment process, from intake to termination (and beyond).
Drawing from her own successful online practice, in addition to training thousands of professionals on telemental health, Gilbertson’s straightforward, conversation style allows clinicians to see themselves in her case examples and clinical decision making.
Designed with both the seasoned and newly minted therapist in mind, this guidebook provides a map to the essentials of a successful online practice.
Drawing from her own successful online practice, in addition to training thousands of professionals on telemental health, Gilbertson’s straightforward, conversation style allows clinicians to see themselves in her case examples and clinical decision making.
Designed with both the seasoned and newly minted therapist in mind, this guidebook provides a map to the essentials of a successful online practice.
Meet the Expert:
Joni Gilbertson, MA, NCC, LCPC, LMHC, BC-TMH, CTMH, is a Certified Clinical Telemental Health Provider, a Board-certified Telemental Health Provider, Licensed Clinical Professional Counselor in Illinois, Licensed Mental Health Counselor in Florida, and the owner/founder of Gilbertson Counseling Services. She has over a decade of experience seeing clients using distance counseling with specializations in domestic violence, anger management, and relationship counseling. Joni uses distance therapy to assist individuals, couples and families with everyday coping in areas such as relationship, depression, suicide, and general coping skills. She is also experienced as a clinical counselor supervising a mental health staff within a hospital setting and within her clinical practice.
Joni completed many trainings in distance counseling and completed and edited numerous online courses for telemental health. She is a certified trainer in mental health first aid and motivational interviewing, and she carries certifications in domestic violence facilitation and selective other methods that enhance client awareness. For many years she trained mental health agencies, children and family services, first responders, jails, prisons, and detention centers on mental health topics along with legal and ethical matters of relative concern to each population. As a former Chief of Probation and Probation Officer, she was responsible for training staff on mental health issues that included motivational interviewing, suicide awareness, personality disorders, substance use disorders and safety strategies.
Joni is also a recently retired college instructor with the Sociology Department where she created and instructed sixteen mental health and legal issues classes. During her employment, she was nominated and presented with the award for “Teachers Who Make a Difference” due to her engaging and dynamic style of teaching. She makes learning an enjoyable experience with her passion for the topic of using technology for mental health.
Learn more about their educational products, including upcoming live seminars, by clicking here.
Joni completed many trainings in distance counseling and completed and edited numerous online courses for telemental health. She is a certified trainer in mental health first aid and motivational interviewing, and she carries certifications in domestic violence facilitation and selective other methods that enhance client awareness. For many years she trained mental health agencies, children and family services, first responders, jails, prisons, and detention centers on mental health topics along with legal and ethical matters of relative concern to each population. As a former Chief of Probation and Probation Officer, she was responsible for training staff on mental health issues that included motivational interviewing, suicide awareness, personality disorders, substance use disorders and safety strategies.
Joni is also a recently retired college instructor with the Sociology Department where she created and instructed sixteen mental health and legal issues classes. During her employment, she was nominated and presented with the award for “Teachers Who Make a Difference” due to her engaging and dynamic style of teaching. She makes learning an enjoyable experience with her passion for the topic of using technology for mental health.
Learn more about their educational products, including upcoming live seminars, by clicking here.
