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By Ofer Zur, Ph.D. & Azzia Walker, B.A.
An earlier/shorter version of this article was published in the Independent Practitioner, 31/1, pp. 12-17.
Table Of Contents
Online Social Media Sites and Psychotherapy
Questions for Psychotherapists to Consider
Confidentiality and Social Networking
Social Networking & Dual Relationships
Digital Divide & Ethical Divide
Additional Considerations
Informed Consent & Social Networking
Summary
Modern digital and Internet technologies have not only proliferated across the globe, but also have raised many complex clinical, ethical, and legal issues for psychotherapists, counselors, social workers, psychiatrists, administrators, and other mental health care providers, as well as for clients, patients, and other consumers of mental health services. Barnett has appropriately titled his recent article on the topic, “Psychology’s Brave New World: Psychotherapy in the Digital Age.” The exploration of the intersection of digital technology and psychotherapy is in its infancy. Some of the issues being explored include e-mails between therapists and clients, clients Googling their psychotherapists, psychotherapists Googling clients, therapist self-disclosure , issues of confidentiality and privacy in the digital age, and concerns with the digital divide, most commonly experienced between older psychotherapists and younger psychotherapists and between older psychotherapists and their younger clients. This paper is one more step in the preliminary exploration of these new, exciting, and complex territories. It is an invitation to contemplate and wonder about these matters, rather than prematurely proposing rigid rules and restrictions. More specifically, the main goal of this paper is to explore the complexities of online social networking, such as Facebook, LinkedIn, and Twitter, as they relate to psychotherapy and other mental health services.
Online Social Media Sites and Psychotherapy
Social networking is one of the most common forms of communication in the 21st century. With over 2.19 billion monthly active users of Facebook in 2018, inevitably, increasing numbers of psychotherapists also have profiles on Facebook, LinkedIn, or accounts on Twitter or other social networking sites. As is the case for many professionals, some psychotherapists’ profiles are personal, while others are strictly professional. For those therapists who have personal information on their profiles, some include detailed personal information while others give the bare minimum. Some therapists use privacy settings to protect their personal information, while others do not. Those who do not use the privacy settings do not because they either do not know about these options, do not know how, or do not understand what other people can see or not see on their profiles. Increasing numbers of psychotherapists post a profile on Facebook as part of their practices with the primary purpose of professional networking and marketing efforts. One may argue that posting a standard website, online social networking profile or Facebook page is a must for a modern-day clinician. This argument is logically based on the simple fact that all successful 21st century businesses, from Toyota, to GM, and online psychics to local pet stores and car mechanics all have an online presence. The majority of modern-day consumers search for services they need, including mental health services, online. They value information from fellow users on sites such as Yelp.com as much as they would trust the opinion of a close friend. Regardless of whether the original source of referral to a psychotherapist came from a colleague, friend, physician, or from an online search, consumers are likely to review the website of potential therapists and look them up on professional sites, such as psychologytoday.com or goodtherapy.com. Modern-day consumers put increased value on transparency, or more specifically, digital or online transparency. Prior to calling or interviewing their potential psychotherapists, consumers are likely to search for the therapist’s Facebook profile or page, or other social networking profiles.
In spite of the immense popularity and the proliferation of social networking sites, many psychotherapists, counselors, social workers, and mental health clinics and departments have been slow to cultivate a full, interactive online presence. This also occurs in the face of obvious professional and economic benefits. Along the same lines, psychotherapists, mental health departments, psychiatric hospitals, graduate school instructors, and ethicists all struggle to understand the implications and effects of online social networking on psychotherapy and other mental health services. Most mental health professionals are at a loss as to how to adapt their practices to the modern, digital reality. More specifically, many – if not most – psychotherapists and counselors cringe at the idea and dread the moment when a client presents a Facebook Friend Request. They wonder whether it is ethical to accept such a request, and they are concerned with the clinical and relational ramifications of ignoring it.
Psychotherapists, counselors, clinics, and mental health departments who consider posting a profile on social networking must be educated and knowledgeable about the technical, cultural, professional, clinical, ethical, and legal complexities involved. Whether using their own staff or using consultants and experts, they must have a good grasp of the general digital landscape in which social networking operates. They must attend to professional issues, such as professional presentations and marketing, and ethical issues, such as confidentiality and potential multiple relationships. They must consider posting a Facebook page in addition to a Facebook profile and understand the differences between the various social networking options.
This article identifies some of the most important questions surrounding the relationships between social networking and psychotherapy, discusses important issues of confidentiality, clarifies some of the confusion regarding what constitutes dual relationships, and proposes some ideas to guide psychotherapists and other mental health practitioners and administrators in their decisions regarding social networking.
Questions for Psychotherapists to Consider Before Responding to Clients’ Friend Requests
Once a therapist, clinic or mental health department has posted a social networking profile or page they are likely, sooner or later, to face a Friend Request. Following are some areas of concern or questions that psychotherapists and administrators have to attend to when they face a Friend Request from a client:
Confidentiality and Social Networking
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. Following are some general facts and ideas regarding confidentiality and social networking:
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.
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 want your family members listed on that Page for others to see? 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.
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.
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.
Social Networking & Dual Relationships
Dual relationships or multiple relationships in psychotherapy refer to any situation where multiple roles exist between a therapist and a client. The question of whether accepting a Friend Request on a social networking site constitutes dual or multiple relationships, or not, has been raised by several ethicists and professionals. The general answer to this question is that sometimes accepting a Friend Request on a social networking site from a client constitutes a dual relationship or multiple relationship, and other times it does not. Whether or not accepting the request constitutes a dual relationship depends on what kind of information clients are privy to and the nature of the therapist-client online interaction. Following are descriptions of both possibilities:
Scenario #1: Multiple Relationships:
In many cases a client making a Friend Request on Facebook is asking the therapist to engage in a secondary social or professional relationship in addition to the therapeutic one. If the therapist accepts the Friend Request and allows the client to be privy to personal information on the profile and to post comments of a personal nature, this constitutes a social multiple relationship. Similarly, if the therapist accepts the Friend Request and allows the client to post comments of a collegial or business nature, this also constitutes a professional or business dual relationship. Obviously, the next question is whether a therapist should or should not engage in a Facebook-type social dual relationship with a particular client. It is important to reiterate, what psychotherapists should know by now, that dual relationships are NOT unethical, per se. According to almost all major professional organizations codes of ethics (e.g., APA, NASW, ACA), acknowledging multiple relationships is neither always unethical nor always avoidable. They assert that multiple relationships should be avoided if they could reasonably be expected to impair the therapist’s effectiveness or cause harm. Whether dual relationships are clinically advised or are ethical or not is primarily determined by the context of therapy, described earlier on in this article.
Scenario #2: Non-Multiple Relationships:
If the therapist accepts a Friend Request to post on a profile, which is strictly professional or if the therapist allows, through the use of privacy controls, clients to view only professional information and postings on the profile, this would likely not constitute a dual relationship. As long as the therapist has not established a secondary relationship, such as a social, collegial or professional relationship with the client, the sheer capacity of the client to ‘follow’ the therapist’s profile or Page online does not constitute a multiple relationship because a secondary relationship was not established. The client, in this case, has only one role, that of the client and patient and is neither colleague, nor business partner, nor a friend of the therapist. In this case a client can only view professional information on the therapist’s profile that probably can also be viewed on the therapist’s passive website or other professional websites and online directories. Psychotherapists who choose to segment lists of friends into categories must use privacy controls correctly and effectively and be sure to know how they work. This is especially important if the therapist has sensitive (personal-intimate) information somewhere on the profile. Unless therapists are tech-savvy, it is recommended that they consult with a nearby expert – a son, daughter or other digital native – for help in navigating privacy controls.
Digital Natives and Digital Immigrants – Digital Divide & Ethical Divide
One of the biggest factors that determine therapists’, ethicists’ and other professionals’ attitudes and clients’ expectations are their relation to technology. In most general terms the younger generations, generation X and those who were born after them, grew up with technology and view it as an integral part of life, having been referred to as “digital natives.” Baby boomers and older are considered “digital immigrants” as they were introduced to technology later on in life and ‘migrated’ (or not) into the digital land as a young adult or later. It is important to realize that not all digital immigrants and not all digital natives are created equal. While most digital natives are tech savvy by the default of their being born into and around technology, others do not have a knack for technology and computers, nor an inclination. Similarly, Digital Immigrants fall into three major groups: “Avoiders,” “Reluctant Adopters” and “Enthusiastic Adopters.”
Applying these categories to psychotherapists and counselors generally means that the majority of them fall into the “Digital Immigrants” group. From my extensive experience in dealing with psychotherapists in my ethics and private practice seminars, most of them fall into the “Avoider” or “Reluctant Adopter” categories. Obviously, the majority of newly licensed psychotherapists are younger and, by definition, are considered “Digital Natives.” Some of the tensions that therapists experience with colleagues and clients is primarily due to differences in attitudes towards modern Internet technologies and knowledge and capacities in regard to the digital landscape. The younger and the older generations generally significantly differ in their attitudes towards privacy and self-disclosure. From Facebook to YouTube many younger people expose highly personal and intimate aspects of their lives for the world to see, which makes most Digital Immigrants cringe. Young clients may not think twice about sending an e-mail or text with intimate details or posting a Friend Request to their therapist’s Facebook page. It is very important that psychotherapists, especially the Reluctant Immigrant ones, do not arrive at ethical conclusions that are based on technical ignorance or basic intimidation of the latest technologies.
Additional Considerations
Following are a few additional considerations on the issue of social networking for therapists:
Informed Consent & Social Networking
While there is no clear standard of care in regard to online social networking for psychotherapists and a result, many ethicists emphasize the importance of informed consent. Here is an example of a “Social Media Policies” section, that therapist may include as part of the Informed Consent or Office Policies given to clients prior to the first session:
SOCIAL NETWORKING AND INTERNET SEARCHES: At times I may conduct a web search on clients before the beginning of therapy or during therapy. If you have concerns or questions regarding this practice, please discuss it with me. I do not accept friend requests from current or former clients on my psychotherapy related profiles on social networking sites due to the fact that these sites can compromise clients’ confidentiality and privacy. For the same reason, I request that clients do not communicate with me via any interactive or social networking websites.
The 2014 ACA Code of Ethics added a requirement for counselors with an online presence to distribute a social media policy.
See stand-alone sample of a Social Media Policy by Dr. Kolmes.
Summary
Digital technologies, including Google and social networking sites, present numerous professional opportunities and ethical challenges. The ethical implications of social networking with clients, like many other cutting-edge Internet issues, are neither clear nor established. Psychotherapists are invited to proceed thoughtfully and cautiously as they navigate through the uncharted digital landscape.