Managing Facebook as a Mental Health Professional

This article is part of an online course: Digital and Social Media Ethics for Psychotherapists for 8 CE credits

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.

Many therapists are not even on Facebook or they may not fully understand why so many people use it. To be brief, Facebook is a social networking site that allows folks to connect to their friends and interact with them (and their online content) 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 a former 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. This is exactly how Facebook can get dicey for mental health professionals. Facebook is a social space which can quickly overlap into our professional lives making it harder to distinguish between personal and professional activities. Maybe that’s where I should begin.

Personal vs. Professional Roles

As mentioned in my Twitter article, it’s important to consider your purpose in using social networking sites before joining each one. The Introduction to our APA Ethics Code (APA, 2002) for psychologists 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 make the distinction between personal and professional activities less and less clear. Stephen Behnke (2008) discusses the challenges of defining “private” in the age of the Internet and the difficulty in assessing the impact of events from one’s personal life on one’s work related activities.

Facebook and other social networking sites which allow us to “friend,” friends, families, and co-workers alike, are creating unique challenges for mental health professionals. It is tricky enough if our profiles are simply visible to our clients. But if clients or colleagues invite us to become “friends,” on these sites, or we extend those invitations to them—even by accidentally clicking on a link to invite everyone in our 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, and interact with potential or current clients and colleagues, your Facebook presence is already part of your professional space. Accepting client requests to “friend” you can be perceived as an extension of your professional practice. Remember that professional relationships come with legal and ethical responsibilities which do not cease to exist just because you are on a social networking site.

Inviting clients to your personal profile can also be perceived as inviting them into your personal life. Unless you utilize very strict privacy settings on your profile, those who become your “friends” can post and view messages posted to your Wall, they can view your photo albums and read the comments on these albums, and they can see and interact with your other “friends.”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 even necessary for us to add or accept a person’s friend request in order for either party to glean a great deal of information about the other. If you choose to have a public Facebook profile and you do not employ any privacy settings on your Wall, 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. With no privacy settings selected, people can see when you are on the site, when you are tagged in photos or videos, and they can 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, et al., (2009), discuss 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 authors point 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. Psychotherapists with public Facebook profiles need to be mindful that some clients will see their profiles and they should consider the impact that this information could have on their clinical relationships. 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. If not, you may wish to delete information or re-evaluate your privacy settings.

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 have likely always been just a few degrees of separation between many of our clients and ourselves in the past, Facebook makes these previously invisible connections instantly accessible. 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, as seen below.

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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 be troubled by this information, but others may find it disturbing. Access to this information alone may quickly change one’s perception of the clinical relationship. While it may not impair your objectivity as a clinician, it may subtly influence how you regard your patient in a multitude of ways, and it may also have an impact on how your patient views you and your relationship.

Some therapists are managing these challenges by employing the most restrictive privacy settings so that very little of their profile is visible to those who are not their friends. Others are using different names than the ones they practice under to distinguish their personal, social Facebook profile from their professional identity. Others have responded by entering client names into Facebook’s “Block” feature, in an effort to prevent clients from stumbling onto their profiles. For more on this, please see my article, “Should Mental Health Professionals Block Clients on Facebook?”

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 any 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 certainly provide a window for explaining to clients the difference between social relationships and professional ones. It can also create a space to explain how we protect client 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 egalitarian stance is desired by you. 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 the decision for some of your clients. Aside from making your own online activities and relationships visible to your clients, this now means that your client’s activities on their profile will likely be showing up in your news feed.

Do you want to get updates on your clients’ lives out of session, knowing before their scheduled session 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? Might there now be some expectation that you will keep abreast of changes in their lives on Facebook in-between sessions? What if a client expresses self-harm desires on her Facebook Wall? If you fail to act on cries for help on a Facebook page and your client harms herself or someone else, could you be professionally liable for failing to prevent harm? These are questions that therapists will have to consider when they 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 clinical interest? I have met with clinicians seeking consultation with me because they accepted friend requests from clients and later realized they regretted this decision. Deleting a client as a friend can be experienced as especially rejecting and complex—more so than declining the initial friend request in the first place. These are certainly thorny ethical and clinical dilemmas which require consultation and care.

Interaction and Legal Responsibilities

In Patricia R. Recupero’s 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 easier to establish and maintain. Some clinicians may use their Facebook profiles to advertise their practices. Be mindful that 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 Facebook presence 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 a step-by-step walk-through in setting up your privacy settings on Facebook. Be aware that some of the privacy features have changed since these original posts were written, so some information may be outdated. You can check these sites for updates to the original posts.

Another option is creating a Facebook profile which is almost completely hidden (it can be hidden in searches but will still show up in the friend lists of those you are friends with, and it may come up in Friend Finder for those with whom you’ve exchanged email in the past). You can also utilize Facebook’s privacy settings to make the content of your profile visible only to people you add as friends. I highly recommend employing the most conservative privacy settings and being mindful of what you post on the Walls of your friends, if you want to maintain a private life on Facebook.

You can also 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 post a statement that you do not accept clients as friends, and you can disable the ability for those who are not your friends to send you messages on Facebook. You can have settings so that only friends can send you messages, but Facebook no longer allows you to block friend requests from people you don’t know. Now you can limit it only as much to “Friends of Friends,” which is a disappointment for many who do not want anyone connected to a friend of theirs to be able to add them as a connection.

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 regularly removing tags), and making sure that your contact information is not visible to people you do not want to see it. You should definitely utlize Friend Groups if you are connecting to people from different aspects of your life. If you do this, you can restrict certain parts of your profile so that certain groups (e.g., “Work Contacts,” “People I Met Once,” etc.) cannot view them.

As referenced above, some clinicians 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 used to email you which is not always the case.

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.

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One advantage to having a Facebook business page is that you can make this strictly business-related and use it to make announcements related to your practice. This enables other Facebook users to easily share your postings with their friends. 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 “liking,” your page, instead of being “friends” of yours. More importantly, you are not endorsing a particular relationship with them.

For your own protection, I’d advise disabling or at the very least, carefully monitoring Wall posts made by those following your practice, to reduce legal risks that could follow from people interacting with your page. You should be careful about responding to requests for clinical advice on your Wall and be aware that depending upon how you respond, you could be entering into interactions that establish a professional relationship.

Also, if a client does wind up “Liking” your page, 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. For clients who are interested in following your page, you may wish to remind them that they can follow the activity of your page privately by subscribing to SMS or RSS updates. This will notifiy them of new postings without their having to create a public link to the page.

Technical Loopholes

If you do wind up trying to employ Facebook’s ever-changing privacy settings, note that all your privacy measures can be meaningless if you wind up interacting frequently on other users’ walls. While you can set up your profile so that people have limited access to your own profile, 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 all of your postings to their friend’s walls connected to your name. If your friends do not lock down their Walls with the same privacy settings you do, then anyone looking at their profile may view this information.

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 also 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, take heed that 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, it may make sense to consult with a professional with expertise in this area, or someone who can help you to secure and test your privacy settings. This can be a wise investment.

Update June, 17, 2010

Since the first publication of this post in June, 2009, Facebook has made a number of privacy changes.

In December 2009, there was a major privacy update which made it impossible to completely hide your profile. While it used to be possible to keep your profile from being shown to anyone who was not your friend, this is no longer an option. You can still hide your profile from general searches on the site, but now anyone can navigate to your profile if they know one of your friends, and if that friend does not hide their friend list. Another way for users to navigate to your profile is if you share “Likes,” or “Interests.”

In April, 2010, Facebook launched Instant Personalization and forced users to make their “Likes,” and “Pages,” public. Following a number of criticisms, Facebook brought back some of the older privacy settings.

To read more and stay current with news about Facebook changes, an excellent resource is the Electronic Frontier Foundation’s blog. EFF is a non-profit organization which is devoted to protecting your digital rights. You can find links to many of their updates in the reference section.

References

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

Bankston, K., Facebook Privacy Changes Inspire Praise, Optimism, and Skepticism. June 1, 2010. Retrieved June 5, 2010 from http://www.eff.org/deeplinks/2010/05/facebook-privacy-changes-inspire-praise-optimism

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

Lee, Jessica, The Inside Facebook Guide to Protecting Your Privacy on Facebook, May 13, 2009. Retrieved June 5, 2009 from http://www.insidefacebook.com/2009/05/13/facebook-privacy-guide/

O’Neill, N., Ten Privacy Settings Every Facebook User Should Know. February 2, 2009. Retrieved June 5, 2009 from http://www.allfacebook.com/2009/02/facebook-privacy/

Opsahl, K., Updated: Facebook Further Reduces Your Control Over Personal Information. April 19, 2010. Retrieved June 5, 2010 from http://www.eff.org/deeplinks/2010/04/facebook-further-reduces-control-over-personal-information

Opsahl, K., How to Opt-Out of Facebook’s Instant Personalization. April 22, 2010. Retrieved June 5, 2010 from https://www.eff.org/deeplinks/2010/04/how-opt-out-facebook-s-instant-personalization

Opsahl, K., Facebook’s Eroding Privacy Policy: A Timeline. April 28, 2010. Retrieved June 5, 2010 from http://www.eff.org/deeplinks/2010/04/facebook-timeline

Opsahl, K., Six Things You Need to Know About Facebook Connections. May 4, 2010. Retrieved June 5, 2010 from http://www.eff.org/deeplinks/2010/05/things-you-need-know-about-facebook

Opsahl, K. How to Get More Privacy From Facebook’s New Privacy Controls. May 26, 2010. Retrieved June 5, 2010 from http://www.eff.org/deeplinks/2010/05/more-privacy-facebook-new-privacy-controls

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.

© 2009 Keely Kolmes, Psy.D.

To cite this page: Kolmes, K. (2009) Managing Facebook as a mental health professional. Retrieved month/day/year from http://drkkolmes.com/2009/06/08/managing-facebook-as-a-mental-health-professional/.

9 Responses to “Managing Facebook as a Mental Health Professional”

  1. Elizabeth Beck » Facebook for Therapists #2

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  4. Sarah

    Hi Dr Kolmes,

    I would be curious to read a further update to this post, based on all the ways that Facebook has changed and evolved their Fan pages in the past 3 years. So much of the marketing stuff for “holistic practitioners” emphasizes that it’s a crucial thing to do. My initial reaction is to think “not for therapists, that’s a bad idea”, but then I wonder whether I should consider it more deeply. It’s certainly complex and I would love to hear some thoughts on it.

    From what I can gather from Facebook, it appears that you no longer maintain a Fan page yourself?

    Best,
    Sarah

    Reply
    • drkkolmes

      Sarah, I hope to be able to offer an update on this post in the future. The truth is that Facebook’s privacy settings change so frequently, that I have opted to have very little presence there myself. However, you ask about creating a business Page on Facebook. Again, while Pages semi-mask who has Liked the Page on the Page itself, it’s easy to go to search results in order to peruse the full list of people who have Liked a page. So people who are engaged in the confidential delivery of services are still left to struggle with whether they feel it is compromising of privacy to allow clients to Like a Page and whether to restrict comments or interactivity on the Wall itself.

      On the other hand, Facebook offers powerful targeted advertising which is more compelling for many than the various privacy risks it creates.

      For me, I chose to not continue to have a Fan page. However, some people have begun subscribing to my Keely Kolmes profile, on which I don’t add friends. While no psychotherapy clients subscribe to that page, it does replicate again the same privacy issue, although comments cannot be left on my profile.

      It should be noted that I’ve become much more lax about my Twitter followers, partly because of the sheer volume of people following me there, and it became impossible for me to even track who is following me all of the time. This made me worry less about a client being identified. So my personal take on these issues is somewhat gray, although protecting client confidentiality and avoiding problematic multiple roles is still a primary concern of mine.

  5. Using Facebook as a Mental Health Professional » The Counselor Coach

    […] to make for your account.  I came across the following article by Dr. Keely Kolmes titled, “Managing Facebook as a Mental Health Professional” recently, and though it was written in 2009, it has a lot of information you may find relevant […]

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  6. Bernice Greene

    Thanks for sharing your thoughts about boundaries.
    Regards

    Reply
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  8. Georgia B

    I’m so glad you suggest making a Facebook page for a mental health practice. This is such a great place for those in the medical field to keep clients up to date and give prospective patients an idea of who you are and what you do, without disclosing a lot of personal information like on your personal page. I’ve heard that people often go to Facebook pages before they go to the practice’s website because they like to see how they interact with followers and view their ratings!

    Reply

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