With more and more therapists embracing social networking sites like Facebook and Twitter, the question arises — where do you draw the line in terms of boundaries with your patients? Where does a patient’s and therapist’s privacy end or begin on such sites? How do patients and therapists navigate this brave new world of connectedness and “friending”?
Dana Scarton over at The Washington Post has the insightful article addressing this issue by talking to a number of therapists across the country. These therapists have had to deal with their own challenges with social networking sites and “researching” people online once it was brought into psychotherapy by a client or a client’s actions.
Professional associations haven’t addressed this kind of technology in their ethical guidelines, but common sense rules the day. As I just gave a presentation to therapists on this very topic, here’s the upshot of what I had to say about this from a professional’s point of view …
- Feel free to be on social network like Facebook or Twitter. But do not “friend” your clients and do not allow your clients to “friend” you. Become intimately familiar with the privacy controls on these networks and ensure that the general public cannot see personal details of your life you would prefer to share only with your immediate friends and family.
- Develop a social media policy. Years ago, I was recommending that therapists develop and share with their patients an email policy. But now you need a more inclusive policy that covers social networking, emails, and even doctor rating sites. Dr. Keely Kolmes has an excellent one here. Share it with your patients and ensure they understand its highlights in session.
- Anything that is publicly available online is food for thought. While I don’t encourage therapists to investigate and research their clients, if a client has a public blog or journal, the client should be aware that their therapist may be reading it. If a client wants the therapist to read it, I think that’s fine, but clients should know that therapists generally don’t have so much spare time that they spend all of it looking for and reading patients’ blogs, tweets or what-not.
- Setting and maintaining clear boundaries is always the hallmark of a professional therapeutic relationship. Let such boundaries always guide your decision making with any new online tool or technology.
- Share your decisions with your patients up-front. Nothing causes more trouble that having to make up policy after something unintentional has happened. Setting clear policy, sharing that policy, and ensuring your patients understand your policies is always the way to go. Even if you don’t use or intend to use any of these tools, you should nonetheless have a social media policy that states as much.
And here’s why you need to do it sooner rather than later, especially if you work with younger, more technologically-engaged clients:
[Psychologist Stephanie] Smith also has a Facebook account for her personal life. After teenage patients discovered that account and sent her “friend” requests, Smith enacted a policy forbidding past or current clients from engaging her online. She informs new clients of the policy and obligates them to comply.
This is the type of problem that UMass’s Benjamin wants to avoid. “To me, it’s a much bigger issue than bumping into a patient in a restaurant,” he says. “You’re putting out there, ‘Hey, these are my contacts.’ And someone then wants to enter your social circle. It puts you in a position where you must take a stand.”
Here’s the reason I have no problem with therapists being on Facebook or what-not, as long as they understand and set their privacy settings appropriately. Therapists are human beings too, and we’ve long since come from the psychoanalysis days of psychotherapy when therapists were supposed to be these blank slates that had no personal life, no personality, and could share zero details of their lives. While it’s not appropriate for therapists to go to the other extreme, it’s a therapist’s humanity that makes the therapeutic relationship work. (If we didn’t need human therapists, a computer could well be programmed to do all the work of a therapist.)
The key is that when clients and therapists interact online, it’s done in a manner that doesn’t create new boundary issues or problems with the therapeutic relationship itself. This is done by therapists understanding the options they have available to them, thinking about them mindfully and with some deliberation about the choices they are making, drawing up a social media policy, and then ensuring their clients read and understand the policy in the next session.
Read the full article: Google and Facebook raise new issues for therapists and their clients.
43 comments
A nice post. That said, I totally disagree with you about a therapist having a Facebook page that shares personal information if you are practicing responsible psychotherapy. Yet another reason why this medium is not strongly enhancing mental health care consistently and reliably.
Come on, Doctor Grohol! We are not the patient’s friend, and privacy and some level of secrecy is a realistic boundary of the process. And you will read what could be many comments that will excessively argue otherwise, and you know what, my money is on a lot it being axis 2 rationality and deflection.
But, an important post to share, and I applaud you for taking on the topic.
Many therapists have a policy of not responding with self-disclosure to patients’ personal or semi-personal inquiries or questions. At the very least, they weigh self-disclosure carefully. Yeah, yeah, there are exceptions like Owen Renik, but even he weighs self-disclosure carefully, in terms of whether it is in the best interest of the client.
That said…
If the patient is asking something for which there is a direct answer online if the patient were to dig around a little bit, is it at all therapeutically defensible for the therapist not to respond truthfully? Or at least to say, “You can find the answer to that question at e.g. zabasearch.com, blah blah etc. etc.”
I’ve got a lot more to say on this subject, most of it highly cautionary to therapists who certainly must be tempted by the direct, indirect, and pure-name-identification-and-recognition marketing possibilities afforded by the Internet, but let’s start with the above.
You have to make sure that your patients know up front that they can’t be a part of your normal life.
But I think that online activities can actually be a cause of mental stress and shouldn’t be encouraged. People who spend too much time on FarmVille on facebook have lost their job. People are posting negative personal secrets about people on http://www.dirtyphonebook.com and causing cyber-bullying to persist.
The thought that people are sitting around googling me is kinda creepy but I guess it’s inevitable with how technology and the so-called “web20” is changing how we interact with others.
You can set Facebook to make you “unsearchable.” That should prevent clients from “friending you.” Although honestly, I, as a client, wouldn’t do that unless I was feeling very lonely or bordering on “stackerish.”
I like the policy you linked to though. I’ve never had a therapist be that upfront before. I also read the other policies. I think it makes sense to have a “social media policy” If you are going to blog, twitter, etc under your real name or have an easily accessible facebook page.
Joel, maybe I misunderstood the article, but I thought Dr. Grohol specifically stated that therapists be very aware of what they are willing to share.
I can see no harm in having my city of residence or my age visible to all, but even I (not being a therapist or anything) wouldn’t put my full address or relationship status up there for all to see. I guess when you work with people so closely as in therapy, you might well be setting yourself up for being stalked.
I get why you’re weary, Joel (even though I kind of dislike your quip about axis 2 rationality/deflection – did I misunderstand you there, or are you saying that everyone who disagrees with you is ‘disordered’? Nice…).
But what about sharing links, articles you find interesting, etc? They tell you something about a person and might even be of interest to a wider audience, yet are relatively impersonal and reveal no details of your life…
I have to admit, I’d be mildly curious to know which articles or books my therapists found interesting. (I wouldn’t waste my sessions on discussing it, though.) Although, thinking about it, maybe it wouldn’t be such a good idea, after all. Political, religious, etc. views transpire too easily … would I really be comfortable to know that, e.g. we’re on opposite ends of the political spectrum, or that she’s a fervent believer who thinks I’ll end up in hell anyways? Nah…
[On another note, I wouldn’t want to even know about my therapist’s private life via internet, same as I wouldn’t want her to look me up on social networking sites. That’s kind of, taking the relationship outside the office, and that’s not what I signed up for. Therapy is very similar to a theatre rehearsal with its stage/offstage boundary (what happens on the stage, stays on the stage and vice versa, i.e. you leave your personal animosities at the door). It’s useful, and there for a reason. … ]
I’m going to play devil’s advocate here (to an extent as I believe with a certain degree as to what I’m about to say) and say there may be nothing wrong with having clients/patients “friend” you on facebook.
There is a misnomer that “to friend” someone on facebook carries with it a certain level of intimacy, or at the very least, a relationship that extends beyond just a platonic or even acquaintance. In fact, that is just what “friending” may actually be – that is, an acquaintance or just someone who supports you, such as a “fan”
We have injected a certain meaning to a facebook friend, where such meaning may not, and in some cases, doesn’t exist. I have close friends, some of who have over 1000 other friends. Do my friends really have close relationships with all those 1000 people? Not likely. In my own profile, I have colleagues who befriended me, and I of them, but I don’t consider them friends in the traditional sense.
A “friend” on facebook can carry with it a lot of different meanings with regards to the quality and type of relationship one has with a particular person. The term “friend” is therefore misleading. Professional relationships, such as those found in business and medical professions, can just as well be considered “friends” on facebook. The term, though, carries a different connotion offline, and it is why there is such a misunderstanding of “friends” on facebook.
To get back to my devil’s advocate position – it may therefore be acceptable to have a client/patient as a friend on your professional facebook page. Facebook policy prohibits having multiple accounts (such as a personal and professional account). If you have a personal account, then yes, the boundaries should be made clear with regards to friending. However, if your facebook account is a professional account, then what is the harm? What is being argued is basically the term used to describe a relationship, rather than the relationship itself, and we are biasing that relationship based on a misunderstanding of the term. (Yes, some clients may, depending on their difficulties, may blur those lines, but for my devil’s advocate position I’m speaking in more general terms).
Some may say, why not set up a separate page, for example, with “fans” instead of “friends”? Is a “fan” really any better than a “friend”? Similar arguments can be made against even having fans.
Primary account settings, fan pages, and groups each serve different functions and carry with them different settings. It’s up to the clinician to decide which will best suit them and their clients.
Devil’s advocate position aside, it’s probably easier for folks to just not accept client’s as friends.
I said I had a few more thoughts in this arena, most of them highly cautionary to psych professionals. I’m going to share them now.
I’m all in favor of psychotherapists having professional websites. This is the perfect place to share information with the world about your practice, your CV, your publications, your professional teaching, your location, phone, email, fees, insurance arrangements, office policies, etc.
A personal website is also the perfect place to link to articles and other web-based information. A sex therapist, for example, might link to AASECT. It’s also the perfect place for a no-comments-enabled blog. Why no-comments-enabled? It’s too tempting to clients and patients to assume false identities and engage in back-and-forth on comments-enabled website. Yes, yes, those clients could do the same at a place like this. But don’t let perfect be the enemy of good.
Here’s what professional websites don’t have: Friends. Fans. Message boards. Walls. Notes. Pictures of you on your Caribbean vacation.
As far as social media go, I’m extremely leery of Twitter for psychotherapists. It’s so obviously marketing — “Keep me in mind!” It seems to cross the boundary of the frame of the therapeutic hour, to send out to clients (and how do you know that clients are NOT following your tweets?) affirmative communications. You wouldn’t call a client seven times a week. Don’t tweet them. And if it means you can’t tweet your friends as a way of protecting your clients, so be it. Professional life is unfair.
Social media like Facebook: Yikes. Another case of a parent leaving the keys to the car on the counter for the unlicensed 16-year-old to take. Most kids won’t take them even if Mom is out. Some might. But damn, those keys are really tempting.
No objection here to a Facebook presence that does nothing more than steer any curious people to our professional websites. But “professional” Facebook pages that contain self-promoting links to articles where the therapist is quoted, or lists and pictures of fans/friends, etc.? That Facebook presence may be beneficial — it WILL be beneficial — to helping the therapist’s practice to grow. Beneficial to the patients of the therapist? Not so much.
We’ll leave discussion of personal Facebook pages set to maximum privacy for another time.
Bottom line is, here’s what I don’t want clients talking about in the room, or even thinking about in the room: The therapist’s Facebook page. The therapist’s Tweets. The therapist’s… Oh, you get the idea. That’s not why they’ve come. Period, end of discussion.
Okay. I don my combat helmet now for the flak that will come my way! 🙂
“Bottom line is, here’s what I don’t want clients talking about in the room, or even thinking about in the room: The therapist’s Facebook page. The therapist’s Tweets. The therapist’s… Oh, you get the idea. That’s not why they’ve come. Period, end of discussion.”
And you really believe that we won’t think about those things just because you don’t want us to? 🙂
Good post John.
Web 2 brings lots of ethical challenges to us as professionals, and we should not throw caution to the wind. As our professional bodies formulate and catch up with these challenges in the absence of guidelines we should exhibit good sense and vigilance! Keeleys excellent and well thought policy is a great example that clarifies and educates clients with regard to the online client therapist relationship.
A good site to visit is The Online Therapy Institute Wiki which is a space organized by The Online Therapy Institute to allow those interested in the topic to read and post information related to the ethics and legalities of the delivery of mental health interventions via technology.
I’d love to have Dr. Keely Kolmes weigh in here on the issues discussed and the concerns raised. Possible?
Hi folks. Thanks to John for the timely post on therapist boundaries and for the link to my Social Media Policy.
Some responses to the conversation thus far:
@Joel Hassman, MD observed that responsible therapists should not have a Facebook profile that shares personal information. I’d argue that it depends upon how accessible the profile is and whether you are using it to promote your practice. I have a personal Facebook page, for example, on which I’m connected to friends and family, but I do not use the name Dr. Keely Kolmes on that page and it is not searchable. It is also restricted so that nothing on my Wall is visible if you are not a friend, and actually much of it is restricted so that only my closest friends can view my Wall. I don’t feel that this is irresponsible at all and I’m quite comfortable with my right to have a personal life. Where I think it gets messy is when you try to combine the two.
@hannah posted about the value of sharing links and articles that a therapist finds interesting. I’ve been doing that on Twitter and on my Facebook Private Practice page. I was recently asked in an interview how Twitter has affected my practice, and my honest answer is that I’ve never had a client say they found me via Twitter. I think some clients may be (naturally) curious about such things but I also think a fair number of clients are oblivious and not particularly interested in whether or not what I’m tweeting. My choices of what to tweet certainly reveal where my clinical interests lie, but I’m only tweeting things of a professional nature and I think my professional interests are pretty easy to surmise if you’ve looked at my website.
To respond to @DrWayne’s devil’s advocate position, I think your comment is similar to Ofer Zur’s take on friending which is that it may be okay. Dr. Zur argues that it may not even be a dual role so long as your Facebook page is purely professional. My problem with this argument is that it completely overlooks what is (in my opinion) one of our most primary ethical duties to our clients: confidentiality.
A lot of focus gets placed on whether or not forging this connection with the client is damaging and/or whether it’s a problematic type of dual relationship. The APA Ethics Code says we avoid dual roles when it can result in exploitation or confusion about our primary role or duties to a client. However, there is no gray area when it comes to protecting client confidentiality and I’ve always felt strongly that if we accept friend requests from clients, we are sending the message to those clients and to others that anyone else on our friend list may also be a client. I find this highly problematic and feel it’s important to be explicit that clients cannot be found on these lists.
@TPG makes some great points about professional websites and the problems with different sites that allow friends, fans, or followers. I have not enabled comments on my own blog on my website due to some of the points raised in TPG’s comment. When I decided to experiment with having a Facebook Private Practice Page last year, I specifically disabled Wall posts by Fans and chose the maximum privacy settings. I have monitored my Fans closely to be sure clients have not added themselves.
Due to continued conflicted feelings, I decided recently to disable my Facebook page. I just don’t feel that it adds enough value to warrant the extra risk and trouble. I don’t feel the same way about Twitter. Mostly because I don’t have to constantly monitor it and because it’s such a rich resource for me in terms of interactions with other people. But it’s not potential clients I’m reaching out to so much as actual conversations with people globally who are interested in mental health and social media.
Do I think Twitter or Facebook have brought me referrals? Thus far, no. I ask each and every client how they found me and not once have I heard Twitter or Facebook. It’s quite common to hear that another doctor referred them to me, or that they found me via a few specialized sites where I list myself.
Do my clients care about what I post? I assume they might, but you would be surprised at how rarely it comes up. We are busy focusing on issues relevant to *their* lives.
I’m certainly open to conversations about the effect my online activity might have on a client. But the most common response to my handing out my Social Media Policy and talking about that with clients was, “Oh, I don’t really use Facebook, but I appreciate your making your policies clear.”
I do think this will change in the years to come. And it doesn’t mean I’m not mindful of what I post or how it could affect clients. I think it about it a lot. As I think all responsible clinicians using Social Media should.
Dr. Kolmes,
Your points on privacy and confidentiality are well stated and well received.
However…I could argue that those who “friend” or “fan” you, whether clients or not, give up their right to privacy and confidentiality by the simple act of friending you or becoming a fan of yours. I could also argue that friending a therapist on Facebook is kind of like “e-consent” and that some things we regard as sacred, such as privacy, are waived by the person in becoming a friend or fan.
The flip side of this, though, is that I have yet to come across a clinician’s Facebook page in which a social media policy is stated or at the very least, some sort of statement is written explaining the risks of friending or becoming a fan of that clinician. The “proper” thing to do would be state your privacy/confidentiality policy on your Facebook page, along with mentioning what happens when you friend or fan, along with other aspects of social media, as outlined in your policy (which, by the way, is phenomenal – thank you for sharing it).
I think the absence of such policies demonstrate a fundamental misunderstanding and lack of education regarding the impact of social media on the practice of psychology and the impact on one’s personal practice. I’ve attended many workshops on integrating social media into one’s practice and they do a great job showing what is out there, but all fail at discussing the ramifications and consequences (I’m hoping to change that in a presentation I submitted for an upcoming conference).
Though I don’t want to scare anyone, we should remember that the standard of care is measured based on what the majority of our peers would do in a similar situation. The majority of my peers do not have Facebook pages, are not practicing psychotherapy online, etc etc. There are also no universally accepted guidelines that exist covering this topic. That puts all of us who want to at a disadvantage.
Again, my devil’s advocate position aside, better safe than sorry.
Thanks sincerely to Dr. Kolmes for her detailed responses.
Two empirical questions for her and/or other therapists reading here who use Twitter as a sender (I don’t):
a. Do you Tweet to your clients/patients?
b. Is there a way to filter out clients/patients when they sign up for your Twitter stream? (I read that Microsoft’s Steve Ballmer set up an anonymous Twitter account. If he did, can’t patients/clients?) http://www.ditii.com/2010/03/04/steve-ballmer-acknowledges-of-anonymous-twitter-account-during-sme-west-keynote/
@Dr Wayne, you may have misread my comments about Facebook. My entire point was that I don’t allow clients to become Facebook friends or fans due to confidentiality issues. So I think we’re in agreement here.
Yes, it’s true that non-clients who become my Fans are giving up privacy, but I have no commitment of confidentiality to those who are not in treatment with me. I spend enough time worrying about client confidentiality without starting to worry about those who aren’t in my care…but it’s true that there is always the risk that a current Fan (who is not a patient) could decide to contact me for an appointment which is a whole topic not yet addressed in much of the discussion on these issues.
My Dr. Keely Kolmes Facebook profile states simply, “I do not accept friend requests.” My Facebook Private Practice Page has always said: “If you are a client of mine, please do not fan this page.”
I agree with you that it would be good if clinicians with Facebook pages ensured that people “landed” on the Page with the statement since Wall posts quickly get buried on Facebook.
@TPG, I’m not sure what you mean by do I Tweet to my clients?
If you are asking do I @reply them, then no, I do not publicly interact with my clients on Twitter. It’s in my Social Media Policy that folks should not interact with me this way. This does beg the question of whether current patients are following me under pseudonyms that I’m unaware of, which could be possible.
If you mean is my professional Twitter account public and can it be viewed by clients, then sure. You can’t filter out your followers unless you have a locked, private account or unless you specifically block a particular user.
I have no problem with my clients reading my public tweets since I’m not tweeting personal information. In my Social Media Policy, I recommend more protected ways of following me to protect their privacy/confidentiality if they choose to look at my twitterstream.
I *never* tweet about my personal life or my client sessions. Not even to say that I’m waiting for a patient or had a good session. I don’t want my clients to read about themselves in any shape or form–even such veiled references–on my Twitter account.
Hope I’ve clarified. Thanks guys!
P.S. @Dr Wayne I’d love to know what/where you’re presenting if your proposal is accepted. Thanks for the kind comment about my Social Media Policy.
Sorry, Dr Wayne might be talking like he is just playing devil’s advocate, but, he is only right and responsible. Appropriate therapists and people active as providers in mental health care either do no have Facebook pages, or have them as aliases and it is hard to trace.
The longer people legitimize being prominent on the internet and are practicing health care interventions, it only feeds the adage of “hear the lie enough and it becomes the truth”.
And the people who defend this thinking the most are the ones who seem to benefit from it. I don’t know K Kolmes, and perhaps this person is an exception, but, it is about accountability in the end.
Hey objective and unbiased readers, if you have or are currently seeing a therapist and somehow stumbled onto a Facebook page of theirs, wouldn’t it be at least odd or a bit uncomfortable reading personable things about them never shared in the office?
Wow, how the intricacies of therapy seem so minimized and rationalized these days. Perhaps why the field is in trouble as a craft, eh?
Board Certified Psychiatrist
Here’s what I got out of this exchange, as my takeaway. It’s a bit different from Dr. Grohol’s initial formulation.
A. Professional websites: Great. Don’t enable blog comments.
B. Professional Facebook page: Okay, but merely to steer people to your professional website. No fans, friends, postings, walls, blah blah.
C. Personal Facebook: okay if under pseudonym. Otherwise too tempting to clients/patients. Possible exception for personal FB pages with maximum privacy enabled. For example, no friends visible
D. Twitter: Again, okay if under pseudonym. Otherwise it shakes the frame of therapy too much if patients can sign up for Twitter stream.
I know that this is erring on the side of caution, but you wouldn’t know if you had a problem in this arena until it was a problem…and then it could be potentially a huge therapeutic problem. Better safe than sorry.
I am a client that has an excellent relationship with my therapist… I am his friend on facebook.
It has not caused any problems in the office. if anything it has helped with trust issues.. come om people it’s 2010 and.. someone needs to step out of the box
Hi there,
I have to say that I have been meaning to comment on this issue for quite some time. I am an addictions counsellor and I have a facebook – guess what – I have “friended” clients! AJ above said “someone needs to step out of the box” and I have decided to do just that. Should I be shot down? Should I be stripped of my “counsellor” status?
I think not – I really do believe in privacy, but I also highly agree that the most “helpful” thing is to lead by example. I have been living a clean and sober life and I think it really helps clients to indirectly see my struggles as a human being. Plus, the majority of my clients are in the “youth” age – and guess what, most youth are on facebook! I rarely comment on status posts or anything like that – but if a client has had a personal breakthrough – I am usually the first person they tell! I see myself as the “stand in sponsor” until they get one, and that works for people! I am not about to shut out something that works 🙂
Like in any profession, therapists are from brilliant to… the lowest side of spectrum. I was helped or, like now, I was brought almost to my breaking point. I decided to do not talk with a therapist who is not able to humanly exposed himself/herself and let me see if we could be a match in intelligence, education, experience and maybe personality. Disclosure brings disclosure and I don’t think I would trust someone over a limit if I would talk like with a computer who has a pre-established set of Knowledge about its hardware and software to show me no matter what kind of user I am.
A therapist who is not interested of how I would react in my relationships as a human being, be it on line – there is a facet of our social way to behave – or in what range I am capable to respect boundaries, without being warned, will not be a therapist that I would choose. For a lot of people it’s enough hard to talk even with friends about some problems; how to talk with a therapist that I see him/her like a stranger? Yes, sometimes you share with a stranger slices from your life but you do not expose entirely, as a whole in front of them!
Joel Hassman, MD wrote, “Hey objective and unbiased readers, if you have or are currently seeing a therapist and somehow stumbled onto a Facebook page of theirs, wouldn’t it be at least odd or a bit uncomfortable reading personable things about them never shared in the office?”
No. What happens in the office is about me because my therapist is competent and forthright. I am not someone who believes that my therapist just disappears into a puff of smoke at the end of the appointment! 🙂 He has a life. I would actually be more suspicious of a professional adult who does _not_ have any online presence.
Speaking of online presence, Dr. Hassman, it isn’t just having a profile on facebook that reveals information. Those can be locked – and should be. Using only the name you signed your posts with here, the simplest google search turns up your professional information, as well as events/causes you donated to, posts to other blogs, and some very strong political language.
I don’t say this to shame or silence you. But these days, it is important to know what is very public (blog post comments using one’s legal name), and what is more discreet or well-boundaried – locked and well-considered social networking presence. The majority of clients are going to use google to find your phone number, get directions to your office, or read client reviews. Other things will turn up as well.
Is the field in “trouble as a craft”? I hope not, because my fellow students and I are working diligently to become good therapists. The internet might have changed what clients find out about us, but my guess is that there will always be ways to connect, transform, and heal.
@TPG, I wanted to ask if you’d be willing to say more about one of your comments. You said:
>D. Twitter: Again, okay if under pseudonym. Otherwise it shakes the frame of therapy too much if patients can sign up for Twitter stream.<
I think of the therapeutic frame as the time, place, fee, and how the client and I work together. A big part of holding the frame is that we focus on the client's issues (not mine) and–when it comes into the work–our relationship. I see my online professional life as outside of the frame, unless the client sees some need to bring that back into the room or if it is having an affect on the client. In that case, discussing the affect of my other professional activities on the client then may become part of the frame which I see as in the room and actual sessions.
I see one's professional Twitter presence as their professional presence in the community. I liken it somewhat to working in college counseling centers when offering community outreach services or lectures to classes when an event affects the community. You are sometimes visible in the community as a mental health professional and your clients may see you acting in this role outside of your therapy sessions. When I worked in day treatment settings, it was also true that clients who met with me individually saw me in multiple professional roles, sometimes facilitating interactions in the milieu, sometimes speaking in group meetings or running groups.
I view a professional online presence similarly. Some of us are teachers, writers, and lecturers as well as providers of clinical care. This is part of our professional existence. We don't exist in a vacuum only in therapy sessions, but we may still be capable of holding the frame with our clients.
So given my view which is undoubtedly informed by my integrative theoretical models and my experience in community mental health, I'd love to hear you say more about how you feel viewing a therapist's professional Twitter stream could compromise the frame of therapy?
And is this informed more by theoretical perspective about therapist as blank slate for projection or some other ideas? I'm genuinely interested in understanding more about your thoughts on this and how you think it could negatively impact the relationship to view one's therapist acting professionally in other contexts.
Thanks so much for all your thoughtful comments. I'm reading everyone's contributions and even the most strongly expressed opinions on both ends of the spectrum with appreciation and interest.
Some people are wary of the internet, as professionals, and their not being on the internet does not infer some hidden agenda, as I infer in the above comment by TT. Also, I would not use my name if I thought it would be harmful or counterproductive at some sites I have visited that people can google to find such contacts. In this day and age of more “anonymous” commenting, where is the reliability and accountability to that? I sent a comment once as anonymous, and then realized that was not for me. I have used aliases in my travels, but the blog authors know who I am as I contact them via their own personal email so they can validate my comments have a level of expertise.
Again, this medium has it’s strengths. But boy does it have it’s weaknesses too, and so many are quick to dismiss them.
@DrKolmes — I definitely want to respond to your question about Twitter and the therapeutic frame in detail, because I think I’ve got something important to say. But I can’t get to it with the focus I want until the weekend. Watch this space!
I read a little bit about social media policy and therapists online here and there. Because of how small a community I currently live in, I deleted my MySpace page and modified my Facebook privacy settings. There are some things in my life I have a right to keep private. This is not because I am living a double life nor is it because I have things to hide, and not that anyone else does either. I think this comes down to a personal choice on the part of every health professional. We know that by having these pages there are some risks involved. As long as we acknowledge this and take precautions to safeguard our information, I see nothing wrong with having an FB page. As for adding clients, I would not do that due to confidentiality and privacy issues for the client.
Interesting discussion – extremes at each end. As a patient, I don’t think we should expect therapists to avoid social networking sites with their real name. Part of the “fun” and “pain” of these sites is to reconnect with past acquaintances.
I have searched for my T on facebook and found that she has signed on in the course of my therapy. Her privacy settings are high, although I can view her list of “friends”. Most are family members. I have never “friend requested” her, nor would I. Sometimes it’s nice to look at her profile picture – particularly on long breaks. Of course, I’ve never told her I’ve discovered her page. She already knows I care about her.
@Dr. Kolmes, I said that I think psychotherapists should not Twitter under their own name because it shakes the frame of therapy too much. You said you thought the therapeutic frame was more limited, and that…
“I see one’s professional Twitter presence as their professional presence in the community. I liken it somewhat to working in college counseling centers when offering community outreach services or lectures to classes when an event affects the community. You are sometimes visible in the community as a mental health professional and your clients may see you acting in this role outside of your therapy sessions.”
Here’s why I think you’re setting up something of a straw man and then smashing it to bits: It is one thing to be visible in the community, and quite another to communicate affirmatively with clients who are monitoring your Twitter stream. It is the difference between a client going to your professional website to get the link to your latest article in e.g. FAMILY NETWORKER and your sending them an affirmative link via email or leaving a phone message for them to tell them about that article.
Psychological practice, in my opinion, is based on the flow of affirmative communication coming from the client to the therapist, relatively unimpeded. Yes, on occasion, a therapist might contact a client, but it’s almost always about something related to the room.
This limitation, in some ways, keeps the room sacrosanct, and the relationship sacrosanct. To me, this is NOT an issue of keeping the therapist a blank slate in the Freudian or Kleinian sense. I am in favor, I suspect, of more self-disclosure of therapist emotional countertransference, if I think it’s therapeutic, than many of my colleagues. What Twitter does, though, is allow the client to tap into an affirmative steam of information coming from the therapist that is not about what’s happening in the room. Even if the therapist never tweets about something personal — and even a “Happy Easter” or “Happy Passover” is personal, in my opinion — the frame gets unnecessarily shaken in the wrong direction by Tweets.
Here’s the solution: Tweet away under another name, and let all your professional colleagues and contacts know what that name is by private email. Don’t tell anyone else.
TPG, your last comment is on the mark for me, but with this quick fix mentality that pervades this society, and rationalization that the internet and these other superficial communication interactions just make things easier and “to the point”, I believe a lot of therapists are just dumbing down the therapy experience.
We are not friends or buddies to our patients, we are providers. And if psychotherapy programs or mentors are teaching this type of mentality, that we are to be folksy and intimate (not sexually but personally) then the programs haved failed to maintain the appropriate boundaries and decorum that makes therapy effetctive.
Which, in my opinion, is why therapy is being relegated to being a distant intervention these days. After all, why pay for someone to engage in therapy if all you need is a friend!
@DrHassman, I’m honored you agree with me. That said, my sense is that a goodly percentage of therapists, maybe even the majority, don’t want to be friends or buddies with their patients. At the same time, they’re trying to figure out the social media thing. That social media thing is still very new, and the marketing temptations are considerable. One hopes that this post by Dr. Grohol (thank you, Dr. Grohol!) and the responses that follow it will sound some cautionary notes — okay, let’s make it a clarion bugle call! — for mental health providers to heed.
Interesting article and comments. I believe that a social networking presence is problematic for mental health professionals because of the unavoidable dual relationship implications and the likelihood of some eventual misjudgment or error in online interactions with clients. It’s not worth the risk. A web presence for a psychotherapy practice can be a helpful tool for therapists and clients alike, but it is probably best maintained in the form of a “static” informational web site (e.g., containing directions to the office, forms to download, a brief CV, insurance policies, etc.).
That said, anyone, including mental health professionals, should be able to inhabit the online world as long as they follow some basic rules of decorum and discretion. The same applies to the real world. Although I know that I could run into a client in any public space, I don’t confine myself to home after business hours or wear a disguise when I go out. Instead, I keep the possibility in the back of my mind and plan accordingly. Similarly, I enjoy using Facebook to connect with family and friends, especially those at a distance, but I protect the privacy of my personal profile.
I was taught that the tired old “blank slate” mentality is not only a misinterpretation of Freud’s work but also inhibitory to a strong working alliance. I would go a step further to say that, in the information age, it is futile. Anyone with access to the internet, a camera, and a good working knowledge of public records can find out a great deal about you whether or not you have a Facebook account. There is nothing we can do about that; it is very difficult if not impossible to prevent stalking or cyberstalking. We are still people who inhabit the world outside of the therapy office. We have a duty to maintain appropriate professional boundaries, but we also have an obligation to care for ourselves and maintain the relationships that enrich our own lives. For some of us, that means using the internet to stay in touch. With reasonably effective privacy protections available to us, why not?
Maybe readers of this post and thread might want to peruse through the April edition of the Psych Times, http://www.psychiatrictimes.com , and look for a column by Gonzalo Perez-Garcia entitled ” Challenges Face by Psychiatrists in the Internet Age”, a piece that does make mention of points I have been advising in this thread to some degree.
Here is the last paragraph, you read it and hopefully the rest of the article and formulate your own opinion:
“As psychiatrists, we strive to preserve anonymity with our patients. But as human beings in the Internet era, we are faced with a wealth of tempting electronic venues to share our lives. The problem is that by putting personal information for friends on the Internet, we also share our personal information with the world.”
The road to hell is paved with good intentions. I wish I could remember which supervisor first shared that with me as the guideline to what doctors should remember in their quest to provide for the community they serve.
Rationalizing and minimizing making the therapy process too personal has costs. A responsible therapist won’t underestimate that perspective. And patients are not in a position to alter that basic tenent.
Read the article, hope the link is correct.
Dr. Hassman, would love to be able to email you with a basic question. Hate to say it but googling your name, I haven’t been able to find your contact info.
Ssmara:
If it is a basic question, I would like to ask you note it here at this site, as I do not engage in any treatment interactions on the internet, per the above comment prior. Besides, maybe the question could be of benefit to others who read here. If it is personal though, and yet not seeking out a psychiatric intervention, I would be agreeable to let Dr Grohol be a middle man and forward your email address to mine and then I could reply. That is the best I can do.
Thanks for the interest.
Sincerely,
Joel Hassman, MD
Dr. Grohol was correct that my original article focused on the question whether there is dual relationships or not when therapists accept clients as FB friends. At his and other colleagues’ suggestion I have added a section on the important issue of confidentiality (at http://www.zurinstitute.com/socialnetworking.html#confidentiality ) to the original paper.
@TPG I need to respond to this part of your comment. You said:
“It is one thing to be visible in the community, and quite another to communicate affirmatively with clients who are monitoring your Twitter stream. It is the difference between a client going to your professional website to get the link to your latest article in e.g. FAMILY NETWORKER and your sending them an affirmative link via email or leaving a phone message for them to tell them about that article.”
I disagree with such a characterization of Twitter. To liken one’s posting of articles on a public site and compare it to sending direct email or leaving phone messages to clients is to completely miss the nature of Twitter.
Twitter is a public bulletin board. It is not a private, direct messaging system. Those who choose to view a Twitter stream are making an active choice to follow a public stream of information. It is in no way like passively receiving a private phone call or email in which the therapist has an intended recipient.
A client accessing my Twitterstream is actually behaving quite similarly to your example of visiting my website to read an article. It is a self-directed choice on the part of the client. It is not an action *I* have taken.
Again, I will reiterate that I do not send links *to* clients and I do not interact with clients on social networking sites. If clients choose to visit my Twitter page and view it to see how I interact with other professionals (the only people I follow on Twitter), then this is something they do of their own volition, not by my directive, invitation, or suggestion. And I do not call or email clients and suggest links to them.
To all the therapist’s who think it’s okay to share or post their personal lives on face book or twitter I would have to say – not a good idea. From a patient perspective it is just not good for us to have access to that info – it changes things. It takes the professionalism out of what you do and can often damage your credibility. I know, I had a therapist who told me things from his personal life and it would have been better if he hadn’t.
Just be careful out there people.
Having read Sheila’s comment above equally echoing my general point that was my first response to Dr Kolmes’ comment, that I challenged saying Twitter is a benign communication stream.
As a practicing psychiatrist for more than 17 years now, pay attention to what are the true boundaries between patients and providers, and what are the slippery slopes that clinicians who have trivialized said boundaries are willing to slide down and ignore the bottom. Patients are NOT entitled nor deserving to know a providers’ personal life issues, and it does in fact complicate, if not tarnish the patient-provider alliance. We are not patients’ friends, we are not equals, and we are not to use patients to further our personal needs. And this current alleged technological advancement is yet another example of the growing narcissism of this and other cultures foolish to follow our alleged examples of improving lives.
So, to unbiased and objective readers, pay attention to the providers you interact with who use their computers, phones, and other silicon attachments like fifth limbs, and who use them as adjuncts to their professional purposes. The dialogue alone should reveal the true abilities and agendas.
Mental health care is to treat, not entertain and simplify life experiences. That is why I come back yet again to comment on this and other blogs that cheapen the mental health care process!
@Sheila and @Joel Hassman, MD, I just want to affirm that we continue to be in agreement on this issue in regard to clinicians *not* making accessible extensive personal information. I use Twitter similarly to how you, Dr. Hassman, are using your psychcentral blog comments: to post on professional issues, not personal ones. Take good care.
The social networking world is indeed a slippery slope. I have kept my website and blog pretty clean – good boundaries. Facebook, Twitter, and LinkedIn are another story. I found it easy to join the conversation and post pieces of professional and personal information. Now, mind you, my practice is more on the coaching and positive psychology side, but still…..I see some issues on the horizon and feel fortunate that nothing has bitten me ….. yet.
I was happy to find Dr. Kolmes social media policy. I also accessed @http://socialmediagovernance.com/policies.php to get an overview of many different types of businesses and online communities and how they handle social media policy. I found all the examples to be helpful – and will use parts of templates from outside our therapy world to add to what I found on the “inside.”
My sisters-in law both are newer practicing psychologists.
Often they will quote something bizarre one of their patients said in therapy.
Isn’t this unethical? Or, at least completely unprofessional?
Every time they post something, I cringe.
Something to consider…
My ex is still stabilizing after his bipolar got out of control about a year ago. This past winter he got a therapist and he friended this woman on facebook. Her site is all business but she also shares links, some (like the top 10 best things women can do, how do you know if your with someone too needy, etc….)he likes and reposts on his site, often saying things like “I want that” or “I’m trying to get away from people like this.., etc.” Honestly, from knowing this person for a long time this behavior is uncharacteristic public behavior that gets worse at times, often associated with mania, and I and others have often wanted someone–anyone–to take away his facebook privileges. I also do not at all appreciate how he uses this therapists authority to justify his behavior, attempt to manipulate others such as myself, etc.in such a public manner. Nevertheless, as far as I can tell, the fact that this particular therapist is not considering her clients mental state, maybe not even having a chance to fully uncover it if denial in client is great, seems nothing short of exploitative, to not consider how a post might land and be used outside of therapy seems preposterous, to not consider that your clients networks of relationships and how things like this might land with others within this network (or does the therapist intentionally wish to cultivate an us vs them mentality?)beyond insensitive, and to top it all off, everyone can figure out who his therapist is by simple deduction. I had forgotten the therapists name and then he posted her post and I was like-oh–that’s her. I am actually concerned for his safely because if this is how his therapist practices boundaries I am very afraid he may be wasting his time, or worse, much worse.
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