On Balogun et al. (2025)
When I sit on the floor with my cat Buttons in the evening, my nervous system slows down. Her calm presence does the work. My system finds something to settle against. This is co-regulation, a nervous-system-to-nervous-system process where a regulated person offers “borrowed safety” to a dysregulated one (Dana, 2018), and it is something a video call cannot do. We can exchange information on video, but we cannot be intimately acquainted. This is what Balogun et al. (2025) never really asks: what are we losing when we move social work onto a screen?
The article was mostly what I expected. The digital divide is real. The ethics aren’t completely settled. Social workers aren’t trained well enough. The data on outcomes is thin. What surprised me was the mention of VR and AR for clinician training. That is one of the few uses of technology in the paper that supports the work without trying to replace between the worker and client presence.
The benefits section was mixed. For clients with disabilities, telehealth is genuinely wonderful. A worker can show up on their screen when getting to an office is hard. But the paper’s assumption about vulnerable populations breaks down quickly. Rhoades et al. (2017) found that 94% of homeless adults owned a cell phone, but 56% had turnover in their phones over three months and a third had no internet use during that time. Access exists but is too unstable to support continuity of care. The homeless patrons I worked with at the Decatur Library during my BSW field placement reflected this exactly. Some could not read well enough to navigate a sign-in screen. Many had no working phone when I needed to reach them. Telehealth is not built for that level of instability.
Something that troubled me slightly the discussion of intimate partner violence. The authors describe telehealth as a “discreet” channel for survivors. In practice, intimate partner surveillance is one of the most prevalent forms of technology-facilitated abuse, encompassing spyware, GPS tracking, shared accounts, social media monitoring, and in-home recording devices (Afrouz, 2021). The abuser may literally be in the next room. Discreet access from inside a controlled environment is risky. The paper also does not address how we build rapport over video, which we still do not know how to do well. We were pushed into telehealth by the pandemic, and the field is now treating that emergency response as common practice.
The most significant challenge, long term, is the dehumanization of the work. Insurance companies will push for cheaper services. Once telehealth is normal, AI will be the next cost-saving step, first for paperwork, then for parts of the relational work. My fear is not that AI replaces social workers directly. It is that institutions use cheaper tools as cover to fund less of the relational work. The NASW Code of Ethics is clear on this: “Social workers recognize the central importance of human relationships. Social workers understand that relationships between and among people are an important vehicle for change” (National Association of Social Workers, 2021). If we change the relationship, we are not addressing a side concern. We are touching one of the core commitments social workers
We should have worked through the ethics before adopting telehealth at its large scale. The pandemic explains why we didn’t. That explanation is gone. We need to slow down and check what we’ve already adopted against the NASW Code before going further. For some clients, telehealth is life-changing. But it is also, I think, step one in taking the human out of social work.
On Zhu et al. (2024)
Nothing in Zhu et al. (2024) really surprised me. The pandemic produced the exact conditions that would predict everything the study found. Restrictions forced telehealth adoption. Clients wanted to avoid infection. Providers had to keep practicing and earning during lockdowns. Social stigma made in-person visits feel risky. Under those conditions, of course the providers moved to telehealth. And once the infrastructure was in place, of course they planned to continue. The direction of the change was determined by the external conditions, not by what serves clients the best.
The rate of adoption was about what I would have expected. High during the pandemic with gradual normalization after. The data makes sense.
The one finding that is interesting is the social worker result. Of the five mental health professions surveyed, social workers were the least likely to expect continued telehealth use (M = 2.65). That gap is not a coincidence in my opinion. The NASW Code of Ethics states the importance of human relationships as a core value and frames relationships as “an important vehicle for change” (National Association of Social Workers, 2021). The profession most committed to relational presence is also the profession most resistant to a model that isn’t in line with its values.
The other factor worth talking about is client preference, which the paper ranks as the highest predictor of providers’ decisions to continue. There is a problem here. The survey was conducted in July 2020, at peak pandemic. Client preference at that moment was shaped by infection fear, social stigma about in-person interaction, and the absence of alternatives. The pandemic officially ended in May 2023, and we are now three years past it. We do not have an idea of what client preference looks like in normal conditions, but Zhu reads the snapshot like it is the future.
My personal stance depends on what kind of work I am doing. For LCSW pay-per-session private practice, where clients have insurance and other options, I would consider telehealth as a convenience. For community work with people experiencing homelessness, family violence, or systemic exclusion, I would not. For social work, the presence is the profession. You can sit in the library with someone who has nowhere else to go. You cannot do that on Zoom.
References
Afrouz, R. (2023). The nature, patterns and consequences of technology-facilitated domestic abuse: A scoping review. Trauma, Violence, & Abuse, 24(2), 913–927. https://doi.org/10.1177/15248380211046752
Balogun, A. K., Dada, S. N., Kazeem, O., & Bakare-Adesokan, K. A. (2025). Integrating telehealth services in social work practice for vulnerable groups. World Journal of Advanced Research and Reviews, 25(1), 1984–1991. https://doi.org/10.30574/wjarr.2025.25.1.0248
Dana, D. (2018). The polyvagal theory in therapy: Engaging the rhythm of regulation. W. W. Norton & Company.
National Association of Social Workers. (2021). NASW code of ethics. https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English
Rhoades, H., Wenzel, S. L., Rice, E., Winetrobe, H., & Henwood, B. (2017). No digital divide? Technology use among homeless adults. Journal of Social Distress and the Homeless, 26(1), 73–77. https://doi.org/10.1080/10530789.2017.1305140
Zhu, D., Paige, S. R., Slone, H., Gutierrez, A., Lutzky, C., Hedriana, H., Barrera, J. F., Ong, T., & Bunnell, B. E. (2024). Exploring telemental health practice before, during, and after the COVID-19 pandemic. Journal of Telemedicine and Telecare, 30(1), 72–78. https://doi.org/10.1177/1357633X211025943
Hey Mark,
It’s always wonderful to hear another story about Buttons – it made a really strong intro to your post, reminded me of my own fluffy feline who loves to sit on my lap while I work, and it was an overall great demonstration of the point you make throughout your post – that our biological systems respond physically to one another. Your strong stance that the human connection is not only a benefit but a required ethic of the profession was something I didn’t consider more thoughtfully. Reading your nuanced take on the articles made me reconsider my own interpretations as I was reading it, and the bias inherent in myself. As someone who is immunocompromised, it is easy for me to see the benefits to telehealth without applying more scrutiny to the risks and ways in which is may disservice clients.
I was also particularly convinced by your further discussion on the topic of domestic violence and how often there are multiple forms of technological surveillance and control in these abusive relationships. While I do agree that telehealth may not always be available to the people in these situations, I do think it provides an avenue that may be easier to do compared to in-person. As you referenced the issue of GPS and in-home monitoring devices, a web-chat with a social worker from a domestic violence shelter may be one of the few access points available when other more traceable means may pose a danger to the client.
Overall great post! You really made me think and challenged some of the ideas I had after reading the articles.
Mark, as I was sitting here reading your blog, I had so many “you’re right”, “ooohhh I didn’t think about that”, and “hmm well what about this” moments. One of the points that I was going to make in this comment was that I think that SOME telehealth services can be completed just if not more effectively via telehealth. i.e. teletherapy, but I do not think that social workers can make the switch. Then, I read your conclusion, and realized we were on the same track! As social workers, we are constantly assessing and relationship building. As you said, that is really hard to do when the ONLY contact is virtual. I do think that check-ins and phone calls could be a beneficial way for social workers to use technology. To your point about victims of IPV, I had not considered electronic surveillance, and I think that you have a great opinion on that. I would be curious to hear the argument to your statement because I don’t have one. I will note that the IPV center in my city, has a “safe exit” button which immediately changes the website to Google, but it doesn’t remove the browsing history.
Hey Mark, very interesting read. So far, the readings in this course have made me aware of how significant the digital divide is. I am currently a case manager, and I have clients who have phones but do not have access to Wi-Fi all the time. I may also have clients who are not tech-savvy and do not know how to check their benefits online. I actually did my BSW practicum at a domestic violence agency, and one of the questions we always had to ask those who were interested in services, or if we made a note on the client, was whether the number provided to us was safe. And when we return a call, the agency number is unknown, so if anyone looks at the last call, they are not able to call us back, and I think that is very important in crises.
I like how telehealth has expanded the options people have for the care they receive. Face-to-face services will never go away. However, Telehealth is here to stay, and providers have to make sure that they meet clients where they are to provide needed services.
Mark,
I didn’t have to wonder about your opinion related to remote services – they come out vigorously! Thank you for sharing them so honestly. I truly appreciate it. As it is my job on this end, I’m going to push back a bit and ask you to consider the middle rather than either end of the bell shaped curve.
I don’t think anyone would suggest that the best way to communicate with homeless folk is telehealth. I think what Rhoades, et. al. were trying to report is the reach of technology goes much further than many people thought in 2017. But I would suggest that they don’t get much healthcare at all, right? The lack of consistent suervice delivery in any form is one of the huge difficulties in serving this population. And I know my friends working in homeless services would tell you that you have to visit the camps to truly engage with folks. But when you are trying to get them connected to a health care provider, you will use whatever works. That usually entails driving them there yourself, but I think you get my point.
I do know from working with low income older adults, that their cell phone accessibility is always unreliable, but they also always find a way to get it back. It has become a necessity to survive, and the one thing they know how to do is survival. My lower income older adults were some of the most technologically resourcesful folks I ever met. They are all using Zoom on their cell phones.
That isn’t to say that your points are incorrect. Constancy and reliability in that technology isn’t present for many lower income populations. But I would submit that constancy and reliability isn’t present very much in anything in working with this population. I’m not sure that’s about technology. The digital divide is indeed real – but I would suggest it is another example of a divide that is getting worse in all aspects. I better not get started on my social welfare policy speech.
It is important to remember that these articles were a contemporary literature review – not an experimental study of this technology. Several of our initial articles are literature reviews, because, as I said in one of my initial videos, it’s important to know the state of technoloyg-mediated practice in our profession at this moment in time – or at least at the moment of time when the literature was written. It’s a;lso true that he state of technology-mediated practice when they were reviewing the literature was very different than it is now. By the time you write your first sentence about technology, you are very likely to be incorrect. It’s one of the reasons we have so much trouble getting good data.
I’m afraid I do have to push back on your statement “We can exchange information on video, but we cannot be intimately acquainted.” I think we have to back up a little bit and define some terms here. Doesn’t it partly depend on how you define “intimately acquainted?” I have read some of your colleague’s posts, and several of them have strong, supportive, engaged, and challenging remote clinical relationships. Others would agree with you that such connections are not possible in technology-mediated contact. Maybe we have to go way back to our professional principles and start where the client is?
There are lots of young people who would tell you they feel more connected in a remote relationship, not less. Have they been brain-washed by the technology itself? Maybe? We talk about that this week when you are reading Haidt. But I do know that when I was forced to work remotely with my older adults and spent the hours I did on Zoom, the intensity of the connections were somewhat startling. We used to call it “drinking from an emotional firehose.” That experience hasn’t left people, and many got connected to it. We have an article that we read in the full semester version of this course, where clients found that they had a stronger sense of the therapeutic alliance remotely than they did in person – and that was after the pandemic. It was the professionals who worried about it more than the clients. But the reality is that every clients and every worker will experience that reality differently.
The DV issue and the question of whether a client is “safe” in a remote environment is serious and requires different kinds of management. Some professionals during the pandemic refused to verify child safety checks any way but an in person visit – period. I too was curious about the “discreet channels” comment in the article, so I went back and read it again. I do think that the opporunity to connect from your own home (if you aren’t still with your abuser) can be a comfort for some DV victims. While you are correct about the ability to “hack” etc., I have found that most abusers prefer the location tracking device on the victim’s car. It’s troublesome in more ways than we have time to discuss here, right?
In terms of the issue of cost, I haven’t found anything that would suggest telehealth is less expensive. The cost of sessions is the same from a clinical perspective. We have found that you are expected to offer more of them. In the articles we read this week, you could see where that came into play. I totally agree with you that the system, particularly the insurance system, is motivated to get as much from everyone as possible with giving as little as possible. That is the basic foundation of insurance. And the problems of support for mental health services makes this policy issue even more pressing. But I would suggest these are issues regardless of the medium of delivery.
I really have to push back on your description of technology-mediated practice as a “dehumanization of the work” and a violation of our core ethical tenents. I’m still here. I’m working overtime to bring my human experiences to this class environment. Would it be easier in a classroom? You bet. But I suspect you appreciate being able to get your education this way as opposed to having your butt in the seat every week, right?
I know this is a long response, and I appreciate your willingness to share such salient and important points. My only opportunity to talk about these points is here, so I’m not going to miss the chance. When I got my first computer (and no, I won’t tell you when that was) I took a lot of heat for dehumanizing society through technology. I learned that technology so I could fight the elements that would have done exactly that. I believe that If we (1)keep the client’s needs at the center, (2)are sure to start where the client is, (3)work our butts off to learn as much as we can to be as good as we can, we can manuever through technology-mediated practice and be true to our ethical principles. That’s what I’m fighting for and that’s why I teach this class.
I am truly looking forward to more conversations.
Dr P