The use of text messages or “texting” in professional communication is rarely covered in medical or graduate school courses. Chances are that the only discussion of such a medium occurs when a professor scolds students for texting in class. Pioneering professionals therefore lack guidance for navigating the murky waters of new interactions that can arise during text messaging.

The importance of this new wave of communication and the risks it brings should not be taken casually by psychotherapists. As with any other conversation a counselor may have with a client, safeguards must be in place to properly record and document the texts produced during a patient’s treatment.

Text messaging is the communication of choice for Generation Y, those born between the late seventies and the late nineties, many of whom regard phone conversations and email as obsolete and old-fashioned modes of communication (Yan, 2006). In fact, the popularity of texting amongst all cell phone users has increased dramatically in just a few  years from an average of 9.8 billion text messages sent per month in 2005 to 152.7 billion  monthly in 2009 (CTIA, 2010).

Teenagers (Generation Z) are even texting each other while sitting in the same room. In contrast, many older therapists avoid giving patients their cell phone number because of concern over security issues, the lack of research on how texting affects the therapeutic relationship and treatment and not wanting patients to access them casually after office hours.

Despite therapists' reluctance to text with patients, some of their tasks will soon be conducted via this medium because of a steady consumer push for the markedly increased convenience that, in psychological terms, is almost equivalent to increased accessibility.

Many young people have no land line and subscribe only to a mobile phone service. They are available to text with anyone, anywhere, at anytime from a smart phone kept in their hip pockets.

What is a cautious professional to do?

Is it reasonable to ask a patient to hang up their cell phones, find a landline and call back? Whether we like it or not, we may not have much choice. As this young generation leaves for college, attains the proper education and training, and then goes on to start their own therapeutic practices, we can only assume that professionals will be inclined to embrace more direct and instantaneous communication such as texting (that is, if a newer and more widely adopted technology does not replace or modify texting as we know it in the next few years).

Therapists of today will either follow suit or not, as they struggle to maintain a foothold in an ever-changing and increasingly technological marketplace where coaches, counselors, social workers, psychologists as well as psychiatrists vie for market share.

We may have our interdisciplinary "turf wars," refusing to work in multi-disciplinary settings, failing to adequately refer to each other and seeking to undercut each other's offerings. Meanwhile, consumers seem unconcerned about the zealously-guarded borders between our professional disciplines. Most consumers can't tell the difference between counseling and therapy, nor do many of them they know the difference between psychologists, psychiatrists, coaches or counselors. Eventually, much like any other group vending services to consumers, those disciplines that can best respond to consumer demand will survive. Adoption of technology may be essential to avoid extinction.

As with any emerging mode of communication, the drawbacks of texting and of relying on the mobile devices used to send text messages are only beginning to come to light. Therapists have yet to sit down and establish a uniform set of guidelines that will influence how their colleagues use texting in professional settings. Just as with other electronic communications, therapists must exercise caution and utilize informed consent with their patients if they are seriously considering texting. There are important risks about which patients ethically must be informed.

There is always the potential that a relationship with a patient can take a turn for the worse if a short and simple text message is misunderstood, especially if the therapist is unable to read their patient’s emotional cues as they are reading and writing their text messages. Then there are the  risks to a patient’s confidentiality should the therapist’s mobile phone be lost or stolen. Most mobile phones are lost in highly-trafficked public places, with 40% going missing in taxi-cabs and another 20% in restaurants, bars, and nightclubs (Gross, 2009).

Hidden Dangers: How to Avoid

The number of lost mobile devices is staggering. This it is not at all an uncommon problem. Over a six-month period from late 2004 into early 2005, Chicago taxi drivers reported finding more than 85,000 lost cell phones, 21,000 PDAs and pocket PCs, and 4500 electronic notebooks left behind in their cabs. Statistics from taxi drivers in other metropolitan areas such as London, Munich, Oslo, Paris, Stockholm, and Sydney are similar (Biba, 2005).

The Therapist's Cell Phone

The following vignette illustrates some dangers of relying too much on a "smart phone" for interaction with patients:

The full cost of losing a cell phone is difficult to measure, as it not only entails loss of purchased hardware and software, but also adversely affects a professional's reputation and stature. In 2009 the average total cost of a lost laptop was $49,246, according to a study of twenty-nine organizations conducted by the Ponemon Institute. About 80% of this cost was attributed to data breaches (Ponemon, 2009).

While mobile phones lack the storage capacity and productive capabilities of laptops, they are similar in that they allow access to saved data and wireless communications. This is especially true of smart phones, which enable users to connect to the same e-mail accounts and applications that they use on their computers. A therapist that loses a smart phone may find him or herself paying costs comparable to those of a lost laptop, once the value of replacing equipment, legal expenses,  lost productivity and professional embarrassment is calculated.

Aside from the direct out-of-pocket costs and time spent to remedy such losses, amendments to HIPPA regulations can make data breaches even more expensive. Effective February 18, 2009, the Department of Health and Human Services increased the maximum civil penalty for illegally accessing individually identifiable health records from $25,000 to $1.5 million (Dolan, 2010). Therapists could face the threat of such fines if they fail to install encryption software on their mobile devices.

Losses of mobile devices are common, but how much of a threat do they really pose to the average therapist or mental health professional? The statistics suggest that the possibility of unauthorized access to patient records is indeed a major problem. According to a 2008 survey conducted by Credant Technologies, a data security company based in Dallas, over one-third of physicians and healthcare professionals store patient records on smart phones, USB drives and laptops.

Most of those interviewed admitted that they did not take the necessary precautions to secure data on their mobile devices. Even after HIPAA regulations were amended in early 2009 to further protect patients, gaps remained in securing data. As late as November 2009, only 39% of healthcare organizations had encrypted their mobile devices (Dolan, 2010). Individual practioners on the whole can be expected to be less aware of this problem than are professional healthcare administrators.

The Patient's Cell Phone

In addition to the potential loss, damage or theft that may occur to a therapist's mobile device, similar misfortune may befall a patient's mobile phone. Aside from this, operational problems with wireless devices may inhibit communication. Dropped calls, static, delays in wireless signals and background noise during a cell phone call or in the middle of texting add to the disadvantage of this mode of communication. Such incidents are tolerable in casual conversations between friends but can be consequential during patient-therapist communications.

This series of events puts Dr. Ellen in a predicament. She received a call from a woman that she has never met who clearly is in trouble. The call dropped and she wasn’t able to extract further details, but has reason to believe that elder abuse is occurring. The caller's failure to answer a return call and, worse, the text message certainly provided no assurance that the incident was resolved and that the caller’s father was out of danger. The text message is a concrete record that must be acted upon.

What would you do?

Psychologists must be prepared for such incidents. Similarly, current and potential patients should be made aware of the pitfalls and shortcomings of communication with such limited interaction. For these reasons, among many others, psychotherapists must seek the consent of their patients before engaging in any communication via texting. Boundaries and expectations need to be established with patients during the informed consent process, prior to treatment.

Informed Consent Process

How to make contact and when messages will be retrieved and returned are issues to be included in the informed consent discussion and documented in the written informed consent agreement. The informed consent process might also explain that text messages will be documented and archived just like any other communication. This precaution serves not only to provide the psychotherapist with a record of the patient’s behavior but also safeguards him or her from potential litigious pitfalls. Why?

Consider the following scenario:

If Dr. Jensen had used an iPhone application to print out the text message, what assurances does she have that:

• her own smart phone won't be stolen and that the patient's information, including phone number, won't be compromised by a hacker
• a subpoena issued by an unfriendly attorney could be used to obtain information that will compromise the patient
• the application developer isn't secretly accumulating such information about users of that application.

If a therapist chooses to engage clients or patients with text messages despite the dangers described above, specific precautions are warranted and discussed during the informed consent process. The following steps are safeguards therapists can implement to record text messages securely so that they can be printed or saved for clinical records:

• Use a service such as Mobile Spy (http://www.mobile-spy.com/) to record text messages from Windows Mobile and Symbian OS Smartphones.
• Text messages can be forwarded to the therapist’s email address via applications such as txtForward (http://txtforward.com/), which may be used on Blackberries and Windows Mobile devices.
• Some "smart" phones, like iPhones or Androids, allow the owner to buy applications that can take "screen shots" (pictures) of their text messages. The screen shot can then easily be sent to an email address as an attachment and saved for future archival purposes.

• Final Practicalities

When using the methods listed above or any other means to record confidential patient communications, keep in mind issues of security and privacy. The most important task is to ensure that the patient knows that their text messages are being recorded. Otherwise, feelings of betrayal and distrust may arise if they discover an archive of their messages at a later date.

Therapists may want to reference their professional and state organizations for further information on securing patient text messages. Standards are constantly being updated and as of the publication of this article, the American Psychological Association (APA) does not single out texting specifically in any of their guidelines.

The APA does, however, suggest a conservative and all-encompassing approach to patient records in their “Revised Record Keeping Guidelines.” Under the heading “Content of Records,” there are three subsections entitled “General File Information,” “Documentation of Substantive Contact,” and “Other Information,” which suggest general standards of practice. Among the content to be included with patient records are “extraneous case information and correspondence, and materials provided directly by the client such as journals, logs, or drawings” (Connell, et al., 2010). Depending on how one defines "correspondence," a case can be made that the term can be interpreted to include any text messages between therapist and patient.

Beyond professional guidelines, it is also worth considering that some texting services send information over unencrypted lines to non-secure servers. One can inquire of the companies offering these communication services whether they provide alternative secure methods to transmit and archive patient communications, and if so, what the cost is and what steps need to be taken to use such services.

Also, be ready to be subpoenaed if your patient ends up in court and an attorney wants to see your text-based interactions with that patient. When in doubt over whether you are adequately protecting your patients and your practice, refer to the most recent HIPAA regulations and amendments to ensure that your patients' rights to privacy and confidentiality are not compromised.

As for information stored on a smart phone, anything that can compromise patient privacy should be encrypted for storage. Additionally, the device should be set to lock itself after a period of inactivity so that a password is required to get in, preventing pranksters from misusing the phone if it is lost or stolen. If this cannot be done with one's device, it may be unwise to  that particular information on the device.

A therapist should be able to reach patients in an emergency, such as when the day's appointments must suddenly be canceled. The schedule and the patients' telephone numbers can be kept in the old-fashioned way: in a pocket day planner or a printout. This provides backup in case of equipment failure or if one cannot go online to access one's electronic address book.

Such an address book should be secure and not available to anyone who might come across (or purchase) one's missing handheld device. Such devices (PDAs, smartphones, etc.), when they are discarded or recycled, should be reliably cleansed of any patient information and stored records of texting communications. This may require expert assistance, as simply doing a "delete" may not suffice.

Without the owner's knowledge, texted messages may be stored elsewhere than on the owner's cell phone or other hand-held device. For example, the Google Voice service can automatically copy messages to a GMail account, where security may be less than desirable.

In practical terms, many of the risks involved with texting between mental health professionals and patients will not actually be avoided by the parties involved. While the wise therapist will strive to take all reasonable precautions and to try not to let lapses occur, texting is currently inherently not at all as secure as alternative communication modes.

Advances in technology, equipment, the practices of communication carrier providers and demands of the marketplace will undoubtedly  improve  in the next few years. Until then, many professionals will resist the siren call (and patient requests) of texting, despite its being perhaps the most accessible communication medium to date.

References

Biba, E. (2005, February 17). Lost your cell phone? Call a cab! PC World. Retrieved June 26, 2010 from http://www.pcworld.com/printable/article/id,119702/printable.html

Cellular Telecommunications and Internet Association (CTIA). (2010). US wireless quick facts. Retrieved June 26, 2010 from http://www.ctia.org/advocacy/research/index.cfm/AID/10323     

Connell, M., Drogin, E., Foote, W., & Sturm, C. (2010). The American Psychological Association’s Revised “Record Keeping Guidelines”: Implications for the Practitioner. Professional Psychology: Research and Practice, 41(3), 236-243.

Dolan, P.L. (2010, February 22). Data security breaches often triggered by carelessness. American Medical News. Retrieved June 26, 2010 from http://www.ama-assn.org/amednews/2010/02/22/bil20222.htm

Gross, B. (2009, August 18). Mobile liability. Annals of the American Psychotherapy Association. Retrieved June 24, 2010 from http://www.annalsofpsychotherapy.com/articles/news/30/15/Mobile-Liabilit...

Ponemon, L. (2009). Fourth annual US cost of data breach study: Benchmark study of companies. Traverse City, MI: Ponemon Institute. Retrieved June 26, 2010 from http://www.ponemon.org/local/upload/fckjail/generalcontent/18/file/Cost%...

Yan, S. (2006, December 8). Understanding generation Y. The Oberlin Review. Retrieved June 26, 2010 from http://www.oberlin.edu/stupub/ocreview/2006/12/08/features/Understanding...