Dr. Keely Kolmes

Managing Facebook as a Mental Professional

In my last installment on social media for mental health professionals, I spoke about how to manage Twitter. Now we move on to Facebook which gets a little bit more complicated.

If you’re a therapist who is reading this you may not even be on Facebook or you may not fully understand why people use it. To be brief, Facebook is a social networking site which allows you to connect to your friends and interact with them and their online profiles in a variety of ways.

If you are a therapist who does not consider yourself tech-savvy and you’re already on Facebook, you may have been invited by an old classmate or a family member who wanted to share photos with you. Or perhaps a co-worker invited you so that you could play games or see photos from your clinic’s holiday party. And this is exactly how Facebook can get a bit dicey for mental health professionals. Facebook is a personal space which exists in public and this makes it harder to distinguish personal from professional space on Facebook. Maybe that’s where I should begin.

Personal vs. Professional Roles

As mentioned in my Twitter piece, it’s important to consider your purpose in using social networking sites before joining them. For psychologists, the Introduction to our APA Ethics Code (APA, 2002) states that the code is only applicable to our activities when they are part of our scientific, educational, or professional roles. But popular social networking sites are making the distinction between personal and professional activities less and less clear. In Stephen Behnke’s article (2008), he discusses the challenges of defining “private” in the age of the Internet and the difficulty assessing the impact of events in one’s personal life on one’s work related activities.

Sites like Facebook which allow us to “friend,” our friends, families, and co-workers are creating unique challenges for mental health professionals. It is tricky enough if our profiles are simply visible to our clients (or potential clients). But when clients try to add us as “friends,” on these sites, or we try to friend them–even by accidentally clicking on a link to invite everyone in your address book –the boundaries can quickly become even more complicated.

If you are using your Facebook profile to establish your professional identity or to attract, connect, or interact with potential or current clients and colleagues, your Facebook presence has now become part of your professional space. This means that legal and ethical provisions may now apply to your online activities. Accepting client requests to “friend” you can be perceived as an extension of your professional practice. Again, be aware that professional relationships come with legal and ethical responsibilities which do not cease to exist just because you are on a social networking site.

At the same time, inviting clients to your personal profile can be perceived as inviting them into your personal life. This can send mixed messages to clients, especially if they are unclear about therapeutic boundaries to begin with. If you would never think of inviting a client to a cocktail party at your home with your friends and family present, then you may want to think twice about inviting them to be your friend on Facebook (or approving their friend requests). It is the online equivalent of inviting them into your social circle.

Visibility, Exposure, and Self-Disclosure

Another challenge that comes with Facebook is that it is not necessary for us to add people as friends in order for either party to glean a great deal of information about the other. If you choose to have a public Facebook profile, this means that your clients on Facebook can see anything that you make visible on your profile, including comments made by friends and family. They do not have to be connected to you as a friend in order to view this information. By default, with no privacy settings selected, they can see when you are on the site, when you are tagged in photos or videos, and they may view any other activity that is visible on your profile, including status updates, any games and applications you add, and personal shout-outs on your wall.

Zur (2009), discusses the various levels of self-disclosure that psychotherapists engage in with clients. Therapist self-disclosures may be deliberate or non-deliberate, verbal or non-verbal, and avoidable or unavoidable. The author points out that therapists should be aware that all of their online postings, blogs, or chats may be viewed by clients and that these archives will stay online in some format, forever. Therapists with public Facebook profiles need to be mindful that some clients will see their profiles and should consider the impact that this information could have on their clinical work. It may be helpful to consider when reading your profile whether any of the information contained in it is something you would disclose to each of your therapy clients.

Another type of disclosure that Facebook makes available to clients is information about who your friends and family members are. While it’s true that there may have always been just a few degrees of separation between our clients and ourselves in the past, Facebook now instantly makes visible all of these previously invisible connections. Facebook will even go further, suggesting friends to you because you happen to have friends in common with another user. If you click on the profile of such a user, it neatly list the names of each of the friends you share.

Imagine how you may feel discovering that you and your clients have mutual friends. What if it’s two friends in common? What if it’s twenty? You may have your own varied reactions to having access to this information, but imagine how your client may feel when she discovers the same thing. Some clients may not mind, but others may mind quite a bit. Merely having access to this information can quickly change one’s perception of the clinical relationship. It may not impair your own objectivity as a clinician, but it may subtly influence how you regard your patient in a variety of ways and it may also have an impact on how your patient views you and your relationship.

Thinking Clinically

The APA Ethics Code (APA, 2002), Standard 3.05, Multiple Relationships, states that psychologists should avoid multiple relationships that could impair their effectiveness or cause harm. Therapists would do best to avoid entering into a multiple role with their clients if it could be seen as counter to therapeutic goals and client well-being. Levahot (2009) points out, however, that client requests to add us as friends also raise opportunities for us to explore issues related to trust, relationships, and boundaries, even if we ultimately decide not to grant the request. It can be a nice opportunity to explain to clients the difference between social space and a professional relationship as well as your desire to protect their confidentiality. This can be an extremely beneficial conversation to have with a client.

However, let’s say you decide you would like to be friends with some of your clients on Facebook. Perhaps you work within a theoretical orientation in which a more neutral stance is not desired by you. Maybe it fits more with your culture or personality. Or, maybe rather than having a strict policy of not friending clients, you would prefer to make those decisions on a case-by-case basis, considering whether there is a clinical rationale to support it for some of your clients. Aside from making your online activities and relationships visible to your clients, this now means that all of their activities on their profiles will likely be showing up in your Wall feed.

Do you want to get updates on your clients’ lives out of session, knowing before they come in to meet with you what kind of day they’ve had or that their relationship status has changed or that they were out heavily drinking at a party last night? Or would you prefer to hear news about your clients lives directly from them in-session? Will there now be some expectation that you will keep abreast of changes in their life on Facebook in-between sessions? What if they express self-harm desires on their Facebook Wall? If you fail to act on cries for help on a Facebook page and your client harms himself or someone else, would you be professionally liable for failing to prevent harm? These are questions that therapists will have to consider if they wish to establish online connections with patients.

And what if you change your mind? What if you decide you want to use your Facebook profile differently or you come to believe that it was a mistake to friend the client and it is no longer in their best interest clinically? I have had clinicians seek consultation with me because they have accepted friend requests from clients and later realized that they no longer felt good about this decision. Deleting a client as a friend can be especially rejecting and complex–more so than declining their friend request in the first place. These are thorny ethical and clinical dilemmas which require consultation and care.

Interaction and Legal Responsibilities

In Patricia R. Recupero’s insightful article, “Legal Concerns for Psychiatrists Who Maintain Websites,” she outlines how courts recognize three types of websites. There are passive sites which provide basic business information and which act like home pages or advertisements. Second, there are business sites on which business is conducted. Business sites are highly interactive and are utilized for commercial transactions. Third, there are intermediate sites which are more interactive but do not involve financial transactions. Intermediate sites may offer advice and may invite contact from site visitors.

As Recupero explains, intermediate sites inviting contact from site visitors may lead to unintentional doctor-patient relationships which create legal duties. Many practitioners who do not consider themselves web-savvy enough to create their own websites may wind up with Facebook profiles which are easy to create. Some may use their Facebook profiles to advertise their practice. However, if you are creating a Facebook page or profile to promote your practice, and you enable activity and interaction from clients on your Wall, you are turning your page into an intermediate site. This can create potential legal dilemmas for mental health practitioners as the interaction will need to be consistent with professional standards of care. It also means that you could be having public interactions on the site with people who later become clients which raises additional issues related to confidentiality and HIPAA related communication protocols.

Setting Up Privacy Settings

So does this all mean that you should just forget about Facebook entirely? Not necessarily. It’s possible to enjoy the benefits of Facebook while still protecting your clients and your practice. There are a couple of great resources that provide step-by-step walk-throughs in setting up your privacy settings on Facebook. Be aware that some of the privacy features have changed since these posts were written, so some information may be outdated.

One option is creating a Facebook profile which is completely hidden. You can utilize Facebook’s privacy settings to make your profile visible only to people you add as friends. I highly recommend these setting if you plan to use Facebook for personal purposes, but it can also be useful if you plan to incorporate your professonal identity into your Facebook activities and want to limit access by people you haven’t approved. In this case, only people who you have accepted as friends can see anything about you or even find you on Facebook.

You can also tweak your privacy settings in a number of different ways. For example, you could set up your profile so that clients can find you, but they cannot view your full profile. You could also make it possible for people to see a basic page with your name and photo, but you can disable the ability for them to send you messages or add you as a friend.

Some privacy settings block the ability to click through to your profile but still allow others to see who your mutual friends are. Even if you hide your general friend list from others, if you create a listing that can be seen in search, people will be able to view your mutual friends from your profile page. While you can choose to hide your friends on Facebook from certain friend groups so that some of your friends can’t see who else you are friends with, this option seems not to apply when strangers are viewing your profile.

The privacy settings I most frequently recommend to therapists are removing yourself from searches, making your friend lists private, selecting “only me,” on the ability to view tagged photos and videos, and making sure that your contact information is not visible to people you do not want to see it. You should definitely be utilizing Friend Groups if you are connecting to people from different aspects of your life. It has become easier to quickly add people to Friend Groups, but if you use the Email Finder to add friends, you will have to manually add a person to a friend group after they have accepted your friend invitation.

I have heard of other clinicians who enter the email addresses of clients who regularly email them into the Block List on the Privacy Settings page, to avoid the inadvertent discovery of their profiles by clients. But this assumes clients use the same email address on their Facebook profile that they have uses to email you which is not always the case. If you really want to avoid having your profile seen by clients, the best thing to do is to remove yourself from Facebook searches entirely by selecting “Only Friends,” under Search Visibility. This means that nobody can see you until you’ve added them as a friend, so lost loves, childhood friends, co-workers or family members will be unable to find you. But depending upon how you use Facebook, that may not necessarily be a bad thing….

Profiles vs. Pages

There is another way to use Facebook to promote your practice while keeping your more personal activity under wraps. Facebook offers businesses the ability to create a page instead of a profile. You must first create a profile in order to create a page. But you can keep your actual profile (along with your friendships) private while still having a public page on Facebook. This will allow you to advertise your practice and post links to your blog posts or other professional activities.

One advantage to having a Facebook business page is that you can make announcements related to your practice, and then other Facebook users can easily share your postings with their friends on Facebook. People may still link to your page, but the difference is that this is a one-way endorsement, as opposed to a two-way friendship link. This means that people show up as “fans,” of a page, instead of “friends.” Some of your fans may wind up being friends, family, or even clients. But they could also be readers of your blog, people who like the work you do, or others who just happened to find you and like your content. More importantly, you are not endorsing a particular relationship with them.

For your own protection, I’d advise disabling Wall posts for your fans, to reduce legal risks that could follow from people interacting with your page or your establishing a professional relationship with those who follow you. This can get more problematic if you establish a professional relationship with someone who resides in a state in which you are not licensed. While distance therapy is becoming very popular, most states require that the clinician be licensed in the state in which the client resides. So the safest way to avoid establishing professional relationships on your Facebook page or practicing without a licence, out-of-state, is to disable the Wall. But if you hadn’t noticed already, I tend to have a relatively conservative take on these things. You may be less risk-averse than I am.

Also, if a client does become a fan, you can always discuss this choice with them in-session and acknowledge the potential impact it could have on them. Of course clients have no duty to be private or confidential about their relationship with us, and some of them may feel comfortable with a public link to our pages, or even saying in public that they are our clients. That is their prerogative. But it does not relieve us of our own duty to provide confidentiality to them. Still, for clients who are adamant about wanting to follow your page, they can still do it privately by subscribing to SMS updates of your page. This will notifiy them of new postings without their having to become a fan.

Technical Loopholes

If you do wind up using Facebook’s granular privacy settings, note that all your privacy measures can be meaningless if you wind up posting lots of information on other users’ walls. While you can set up your profile so that it appears as a non-linked name with no photo, activities that you engage in on other users profiles will still be visible. So if you have friends in common with any of your clients, they will see this.

You will have to use your best judgment as to how you want to interact in a public (and regularly archived) space.

Also if you decide that you do want to accept friend requests from clients, know that it is fair for them to assume that some of your other “friends,’ may be clients, as well. This could potentially raise concerns about client confidentiality. As with Twitter, you should be aware that you cannot guarantee the confidentiality of any messages sent to you via Facebook and these exchanges are not HIPAA compliant.

If you have ever emailed with a client, you may each be showing up in one another’s Find Friend searches. It can be all too easy for either one of you to accidentally invite all your mail contacts with a careless click of the mouse. So be aware that friend requests in either direction may have been accidental.

Final Thoughts

As the internet evolves and more clients and therapists are sharing online social spaces, we have the opportunity to think critically about how we use online spaces personally and professionally. It is becoming important for all of us providing clinical care to consider the kind of access we want to permit others (especially clients) to have to our online profiles and the access we have to our client’s lives online. It is especially important to consider not only the impact our private lives are having on our professional activities, but also how we present our professional identities on sites like Facebook which so easily blend the two.

Professional Consultation

The internet is creating new ethical challenges for many of us. If you are a therapist who is seeking further consultation regarding technical, clinical, or ethical issues related to internet technology and your therapy practice, I provide consultation services to other professionals. Feel free to contact me.

References

American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060-1073.

Behnke, Stephen, Ethics in the age of the Internet. APA Monitor on Psychology, July/August 2008, 74-75.

Recupero, Patricia R., Legal Concerns for Psychiatrists Who Maintain Websites. Psychiatric Services, April 2006, Vol. 57. No. 4, 450-452.

Zur, O., Williams, Martin H., Lehavot, K., and Knapp, S. Psychotherapist Self-Disclosure and Transparency in the Internet Age. Professional Psychology: Research and Practice, February 2009, Vol. 40. No. 1, 22-30.