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By: Ofer Zur, Ph.D.
Internet technologies have proliferated in the culture at large and have impacted most aspects of mental health services. These digital technologies have raised many concerns about privacy and confidentiality in regard to mental health services (Bavonese, 2010; Keller, at. al, 2010; Kolmes, 2009, 2010a; Zur, 2010). From the use of e-mails and texts to communicate with clients via video-conferencing to situations where therapists are engaged with their clients via social networking, all have significant implication regarding confidentiality (Lehavot, 2009; Zur 2008a, 2 2008b; 2009).
Issues of confidentiality are not likely to be relevant when psychotherapists use a ‘passive’ website, or what is called “business card” type website, describing their practice and expertise. (Blogs with comments enabled or any other form of audience participation are NOT passive). The reason that this kind of ‘passive’ website does not generally pose any concern with confidentiality is because they do not allow for viewers’ feedback, comments, or responses and do not involve a dialogue or a ‘conversation’ between psychotherapists and clients. They are like a bulletin board, strictly a one-way communication, which enable the therapists to be in control of what is posted.
Social Networking & Confidentiality
One of the most important and relevant issues evoked by the use of online social networking in conjunction with mental health services is that of privacy and confidentiality of communication between psychotherapists and clients. Unlike a passive website, Facebook, Twitter and LinkedIn are interactive–indeed, they are social networking sites. These active, interactive forums require much more care and attention regarding the confidentiality and privacy of the therapist-client communication. Younggren and Harris (2010) appropriately raised an important concern regarding confidentiality issues and social networking sites. They state:
The maintenance of confidentiality is the first risk management issue raised by this type of communication. Most state laws require that psychologists maintain confidentiality. That is, they must be sure that the information that is shared with them by clients, including that person’s identity, remains confidential unless the client authorizes the release of that information. This requirement could easily be violated through the use of a website designed for social networking. For example, if one were to accept a request to become a friend of a client on Facebook, the issue of the possible exposure of that client’s identity to others must be addressed. In addition, just what information will be exchanged should also be addressed, because others might be privy to a client’s confidential information. (p. 11)
Many psychotherapists, counselors, clinics and MH departments use Facebook Pages (rather than Facebook Profile) for public-appropriate interaction. Pages are meant for business, while profiles are generally meant and used for personal/social interaction among friends. While one needs a profile to make a Page, people can become fans of the page without being friends of the profile, and vice versa. Facebook Pages often include information like new products or event announcements; inspirational quotes; links to relevant news stories and other resources; and other matters of interest to one’s colleagues and professional base. As such they are one of the most effective marketing tools for businesses in the digital age.
Although it is intended for business and therefore more appropriate for interaction with clients, a Facebook Page still presents several dilemmas. Kolmes (2010b) explains:
“The biggest problem with having a Page is that you will still have to decide how you feel about who Likes your practice. . . Will you accept current or former clients as people who endorse your Page? Having or allowing your clients to be connected to your public professional profile brings up issues of confidentiality. (“Pages vs. Profiles” section, 1st para). Even on a professionally-oriented Facebook Page, clients-fans can Like the page and therefore join the page and post on the wall. Then, a client may post a therapy or lineally related notes, which could be not only awkward for therapists and other fans but also, in fact, troublesome in regard to confidentiality, privacy, and HIPAA compliance. If therapists, clinics, or mental health departments start a Facebook profile or Page, it is suggested that one weigh the pros of interaction and exchange of ideas with the possible con of fans misusing their access to post confidential communication that can be viewed by others. How one may decide what access fans will have will largely depend on the factors described in this article.”
Generally, communications between friends on a Facebook profile are visible to all friends of the person on whose profile the conversation exists. Privacy settings can widen or narrow the number of people who can view and participate in such conversations; for instance, one can specify that even non-friends can view wall posts and comments; or, one can specify that some or all friends cannot even see the wall.
Similarly, psychotherapists can create a private lock in their Twitter accounts, and people will have to request to follow them, after which psychotherapists may grant or deny access. When it comes to privacy, psychotherapists and administrators must know the distinction between public (wall posts, responses to status updates) and private (private message) communication. However, even private communication – as we know from past, widely reported, Facebook privacy breaches – is not foolproof. Security – online and offline – never is. Most experts agree that e-mail, which is not free of vulnerabilities either, is a more secure mode of communication than social networking sites.
Legally speaking, Dr. Younggren (2010) clarifies that communications between psychotherapists and clients through electronic means, like Twitter and Facebook, are “arguably not confidential.” He also argues that these types of communication are likely to be completely discoverable and in no way protected by privilege.
It is important to note that the Facebook (2010) website makes the following disclosure:
Although we allow you to set privacy options that limit access to your information, please be aware that no security measures are perfect or impenetrable. We cannot control the actions of other users with whom you share your information. We cannot guarantee that only authorized persons will view your information. We cannot ensure that information you share on Facebook will not become publicly available. We are not responsible for third party circumvention of any privacy settings or security measures on Facebook.
Similar to Facebook, Twitter’s privacy policy (at https://twitter.com/privacy) states:
You should be careful about all information that will be made public by Twitter, not just your Tweets.
Clients must be informed about the concerns and issues surrounding privacy and confidentiality in regard to communication via Facebook, Twitter, and other social networking sites. This is similar to the disclosures that psychotherapists must have in regard to e-mails. (More specific ideas for informed consent are outlined below.) In summary, before setting up your social networking profiles on Facebook, Twitter and the like, become informed about the confidentiality and other relevant issues, seek consultation, and when necessary, provide clients with informed consent. Above all, proceed with caution into these new and largely unexplored digital frontiers and keep yourself updated on developments in the field.
Regardless of clients’ inclination to reveal personal or clinical information, it is the therapist’s responsibility to maintain confidentiality and keep clinical information private and confidential. If the psychotherapist runs a Page, he or she (or his/her delegate) should monitor the Page daily and delete any inappropriate comments from clients or anyone else. We recommend addressing such issues – inappropriate posts and the psychotherapist’s action to remove them – with the client at the next session. Another idea for controlling posts from clients is, if the psychotherapist and client are Facebook friends, the psychotherapist can use the profile for more one-way communication, by not allowing any friends to post on the wall.
Or, the psychotherapist can put the client on Limited Profile, not allowing the client/s to see sensitive information.
It is important to note that while psychotherapists and counselors have an obligation to keep clinical information confidential, clients do not have such an obligation. Clients ‘own’ their clinical records and have the right to post anything they choose online regarding their psychotherapy.
Informed Consent & Social Networking
It is important for psychotherapists to have social media policies as part of the informed consent process. If the therapist does not accept clients as Facebook friends, but does accept clients as Facebook fans (on the page), this may be included in the office policies. If being a fan requires a commitment to not disclosing that the client is a client, then that, too, belongs in the policies.
Informed consent is more than a written work to be signed early on and potentially forgotten about. True informed consent involves discussions and dialogues on an ongoing basis if appropriate.
Here are two examples of social media office polices:
As part of an extensive Office Policies, Dr. Ofer Zur proposes the following section on Social Networking:
SOCIAL NETWORKING AND INTERNET SEARCHES: At times, Dr. XX may conduct an online search on his clients before the beginning of therapy or during therapy. If you have concerns or questions regarding this practice, please discuss it with Dr. XX. Dr. XX does not accept friend requests from current or former clients on social networking sites, such as Facebook, due to the fact that communications on these sites can compromise clients’ confidentiality and privacy. For the same reason, Dr. XX requests that clients do not communicate with him regarding clinical matters via social networking websites, blogs, and similar media.
Dr. Keely Kolmes (2010a) discusses her thorough process of developing her Private Practice Social Media Policy and provides an in-depth example of social media policies (Kolmes, 2012). Below is an excerpt:
FRIENDING: I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.
Skype & Confidentiality
Video conferencing, or what is often called Interactive Audio-Visual Technology (IAVT), is one of the most popular forms of communication in the 21st century. As is obvious from its popularity, IAVT offers great convenience in communicating with others across distances.
Skype is one of the most popular sites on the Web. It is a form of IAVT which is free (when used between devices which have access to the Internet) and readily available. While popular and encrypted, Skype neither gives the HIPAA required BAA nor reports to users if there was a security breach. It also does not comply with the HITECH Act of 2011.
As with any technology, there are a number of concerns that have been associated with the use of IAVT in Telehealth and TeleMental Health. Besides concerns with confidentiality, privacy and informed consent, IAVT technologies raise concerns regarding monitoring access, HIPAA compliance, crossing state lines, competence and scope of practice, and record keeping. Prior to using IAVT technologies in TeleMental Health, clinicians must analyze these considerations.
Online Resources
References
Bavonese, J. (2010). Facebook and your practice: Developing your social-networking savvy. Psychotherapy Networker, 34/1, 69-70.
Facebook (2010). Press Room. Retrieved on August 14, 2010 from https://www.facebook.com/press/info.php?statistics
Keller, A., Moore, E., Hamilton, D. Terrell, D., and Hahn, L. (2010). Facebook: Implications for Counselor Education Students, Faculty and Practitioners. Retrieved on March. 25, 2010 from https://www.counseling.org/handouts/2010/102.pdf
Kolmes, K. (2009). Managing Facebook as a Mental Professional. Online Publication. Retrieved on Feb. 15, 2010 from https://drkkolmes.com/2009/06/08/managing-facebook-as-a-mental-health-professional/
Kolmes, K. (2010a). Developing my Private Practice Social Media Policy. The Independent Practitioner, 30/3, 140-142.
Kolmes, K. (2010b). A Psychotherapist’s Guide to Facebook and Twitter: Why Clinicians Should Give a Tweet! Retrieved on August. 15, 2010 from https://www.psychotherapy.net/article/Psychotherapists_Guide_Social_Media.
Kolmes. K. (2012). Social Media Policy. Online publication. Retrieved on August 15, 2010 from https://drkkolmes.com/2010/02/01/updated-private-practice-social-media-policy.
Lehavot, K. (2009). Is Being Exposed All Bad? Implications of Internet Self-Disclosures for Psychotherapists, Clients, and Graduate Students. Professional Psychology: Research and Practice, 40 (1), Feb 2009, 28-29.
Younggren, J. N. (2010). To Tweet or Not to Tweet, That is the Question. The Clinical Psychologist, 63/2, 18-19.
Younggren, J. N. and Harris, E. (2010). Risk Management: Some additional thoughts on social networking. National Psychologist, May/June, 11.Zur, O. (2008a). I Love These E-Mails, or Do I? The use of e-mails in psychotherapy and counseling. New Therapist 57, September/October, p. 23-25.
Zur, O. (2008b). The Google Factor: Psychotherapists’ Self-Disclosure In The Age Of The Internet: Discover what your clients can find out about you with a click of the mouse. The Independent Practitioner, 28/2, 82-85.
Zur, O. (2009). Psychotherapist Self-Disclosure and Transparency in the Internet Age. (Invited lead article to “Focus on Ethics” section) Professional Psychology: Research and Practice, 40, 22-26.
Zur, O. (2010). Record-Keeping of Phone Messages, Email and Texts in Psychotherapy & Counseling. Online Publication – Zur Institute. Retrieved on August 15, 2010 from https://www.zurinstitute.com/digital_records.html.