This year, I had the pleasure of meeting Dr. Susan Giurleo, Ph.D., who led a Core Conversation on Improving Mental Health Through Engaged Communities, and Pamela Rutledge, Ph.D., a media psychologist, who was on the panel Can the Internet Make Us Happy? (as an added perk, you can listen to the audio of this session on the link).

I had two complaints about the formatting of the programming (which I will frame in the form of wishes). First, I hope that future health track panels will not be segregated to a separate campus. This made it more difficult to cross-pollinate with attendees and dip into sessions from other disciplines without committing to a dash to a different venue. Second, I hope that we have larger rooms next year for the health track. I assume that there are many SXSW attendees who might be interested in checking out the health panels but running to different campuses made it somewhat prohibitive for some. It also seemed to assume we only wanted to meet amongst ourselves which may not be accurate.

My session was called Patients/Caregivers on Facebook: Establishing Boundaries Without Barriers. It was organized and moderated by Ed Bennett, Director of Web Strategy at University of Maryland Medical System. We had several fantastic panelists: Jen Dyer, MD, MPH from Ohio State University, Dana Lewis, Interactive Marketing Specialist, and Dan Goldman, who provides legal counsel at Mayo Clinic. I want to thank everyone who came out to see our session (at 9:30am on Daylight Savings Sunday, no less!) and who helped make it dynamic and engaging both in the room, and on twitter. I hope to see you all next year!

Susan Spaight posted a lovely summary of our presentation.

Dana also posted a great recap of the lively twitterfeed of our panel which I’ve embedded below. Please give it a moment to load.

Related posts about this year’s Health track at SXSW:

• Ed Bennett’s blog post about our session
• John Grohol’s summary of psychologists at SXSW this year
• Reed Smith’s post 3 Reasons SXSW Can Change Social Health
• #SXSWH, the SXSWi Health Tweet feed
• Pamela Rutledge’s wrap-up on Psychology Today
• Tracy DiMarino’s summary of our session on PR 20/20

In the last week, I received two separate emails from clinicians asking my opinion on Groupon and other deal-of-the-day marketing sites for psychotherapists. In my experience, if a couple of people are asking me about it, there are probably many others considering it. Are these sites a good idea for mental health professionals? Are there any ethical issues to consider?

There are so many stories about businesses that get flooded with customers after their partnership with Groupon. Some clinicians might get the idea of using such a site to offer discounts on initial therapy sessions. This may seem like a good concept at first. But these forms of marketing are actually not such a great idea for mental health professionals

Let’s look at why.

Confidentiality

Groupon provides daily offers to people who sign up as members of the site. When a member purchases a Groupon, they are making a payment directly to the site.  Groupon then sends you a check and a list of the people who purchased the coupon. This helps you to track your customers when they redeem their coupon. What does this mean? It means that any psychotherapist offering a deal through Groupon is letting Groupon know the names of people who are contacting her or him for psychotherapy. So there is an inherent breach of confidentiality right there. Not good for you, and not good for your clients.

Fee Splitting

Groupon takes a portion of each Groupon you sell. In other words, you are splitting some of your earnings with the site. This is fee splitting. This is what the APA Ethical Principles of Psychologists and Code of Conduct says about splitting fees:

Standard 6.07 Referrals and Fees
When psychologists pay, receive payment from, or divide fees with another professional, other than in an employer-employee relationship, the payment to each is based on the services provided (clinical, consultative, administrative, or other) and is not based on the referral itself.

Since Groupon is taking a percentage of your earnings in exchange for the referrals to your practice, the whole system is also a breach of the Ethics Code.

Avoiding exploitation of vulnerable populations

Groupon – and sites like it –  use the concept of collective buying. This means that a minimum number of people need to sign up for the deal in order for everyone to get it. Even without the breach to confidentiality or the problem of fee-splitting, this is probably not an ethical way to manage the business of psychotherapy.

What if one were to sell more appointments than they can reasonably accommodate? It can sometimes take months for a business to manage the volume of people who have purchased a Groupon. Since the people most likely to be seeking treatment may be vulnerable, having them purchase a session and then queuing them into a long waiting list may be exploitative of vulnerable populations. Since we are also unable to screen the people who purchase the Groupon, we are not in the position to assess their appropriateness for the service they are buying. Suppose they are in crisis or at risk for danger to self or others?

Conclusion

Clearly, it raises all sorts of ethical dilemmas to have people pre-purchase a therapy session through a third party. In this economy, it can be appealing to think that there are creative shortcuts to building a practice and getting people into our offices. But we have to be very careful in considering the impact of the new marketing and social networking tools. If you want to offer discounted intakes for psychotherapy, it’s probably best to offer that to consumers and have them purchase the service directly from you, assessing them at the time of “purchase.”  Groupon may offer great deals for customers, but in this case, it’s not a great deal for psychotherapists who may find themselves in hot water when trying to market discounted services.

I’m pleased to be one of the contributors to this course.

This 3 unit CE course presents four audio interviews by Barbara Alexander, LCSW, BCD with the following speakers:

• Curt Kearney, MA, LCPC – “My Patient Wants to ‘Friend’ Me”
• Keely Kolmes, Psy.D.  – “A Social Media Policy for Your Practice”
• Lisa Johnson, Ph.D. – “Social Media Enhances Clinical Work”
• Frederick Reamer, Ph.D. – “Standards for Using the Internet and Social Media”

There is currently a pre-order special: $35 until January 15, 2011.

After that, the price will go up to $55.

Currently, you must order this by phone: 800-835-9636.

For those who do not wish to take the CE but who still want to listen to the interview, I will upload my segment here in the near future.

Listen to a brief clip of this interview:

The course is Digital and Social Media Ethics for Psychotherapists: Clinical and ethical considerations for psychologists, counselors, and clinicians using the Internet. You can earn 8 CE units by completing this course.

The course offers CE Credits for Psychologists, MFTs & LCSWs (BBS), Social Workers (ASWB), Counselors (NBCC, NAADAC), Nurses (BRN) & More. Find out more about the available CE accreditation.

Course description:

The Internet and social networking are offering a number of new clinical and ethical challenges for those who provide face-to-face mental health services. These challenges include extra-therapeutic contacts between therapists and their clients, questions about what distinguishes personal and professional activities online, and a lack of clearly developed policies related to our online behaviors and interactions.

This unique and first-of-its kind course offers an introduction to various social networking sites and activities and provides guidelines for how to manage the concerns that may arise for practitioners who are using these sites. Applicable ethical standards will be addressed. While this course focuses on issues that may be of concern to clinicians who provide online therapy and who also maintain a presence on social media sites, online treatment is not specifically addressed in this course.

The first section of the course is an Introduction to the clinical and ethical issues that get raised for psychotherapists using Social Media. The second section addresses online transparency of both clients and therapists, inclusive of what therapists may intentionally or unintentionally make available online, and whether they should access client information online. Section three looks at friend and contact requests on sites such as Facebook, MySpace, and LinkedIn, and also examines the challenges of Facebook business pages and the blocking feature on such sites. The fourth section addresses Twitter, Status Updates, and Location-based check-in sites. The fifth section discusses the ethical issues that are raised by consumer review sites and business listings. Section six focuses on email exchanges between therapists and clients, record keeping, and digital security. Section seven provides sample Social Media Policies, and section eight, the last one, includes links to ethics codes for psychotherapists, and additional online resources.

Media psychology

To begin with, let’s be clear that media psychology has some competing definitions.

A new generation of media psychologists is fighting to make clear distinctions between the traditional view of media psychologists: clinical psychologists who appear in the media (for example, on talk shows and reality TV) and those who actually specialize in both media technologies and psychological theory who are studying the uses, experiences, and impact of media on our lives.

This post focuses on the former understanding of media psychology, and not the latter. It is geared towards clinicians who are venturing into social media with the intention of interacting with online audiences.

Many psychotherapists don’t consider a social media presence to be similar to having a television or radio show with thousands of audience members. In fact, most of us start out blogging and tweeting to an audience of zero, never sure how many readers will eventually see our sites. Fewer of us have received any training in media psychology.

However, if you’re a psychotherapist using social media to promote your practice or provide mental health related information, don’t fool yourself: you are acting as a media professional. Social media has become one of the fastest ways to reach an audience, and it often leads to other opportunities to educate and connect with the general public (e.g., interviews, public speaking, and writing articles). It’s important to recognize that your media presence can quickly expand in ways you may have never anticipated.

If you’d like to use your blog or Twitter to broadcast health information, it’s smart to do some research and learn about the ethical responsibilities and potential conflicts that can arise when acting as a media professional. This post will introduce you to some things you should consider when creating a social media presence.

What is your role with your subscribers, readers, and followers?

Who is your audience and how do you plan to interact with them? Are they potential clients? Are they other mental health professionals? Are you educating people about mental health in general, or about your specific areas of focus? Are you trying to give an impression of how you work to market your services? Perhaps you simply want to pose questions to an audience of other clinicians about areas of research, best practices, or challenging aspects of clinical care?

Establishing a professional relationship

If your goal is to encourage potential clients to contact you, you need to take care in how you respond to those making public clinical contact with you. It is easy to violate confidentiality and create an archived record of such a violation when responding to someone asking about becoming your client.

Here is an example: as more people follow me on Twitter, I sometimes scan my @reply list of messages and see replies from people asking about whether they can schedule a session. Others will post public messages and ask how I might diagnose their symptoms. Obviously, we cannot begin a clinical relationship in public and DM-ing (direct messaging) a potential client on Twitter is unwise since it is a non-secure site. Lastly, of course, we may not want to appear rude by ignoring the request entirely.

But it’s not always practical to respond to every query, and certainly not in public.

My best solution has been to Tweet a general reminder now and then that I cannot respond on Twitter to any requests to engage my services and that the best way for people to contact me if they are interested in becoming clients is to directly phone my office and schedule a phone interview.

Some of the legal issues involved in managing potential clients on blogs or other websites are addressed by Recupero (2006). She points out that advice-giving over the phone may be enough to establish a doctor-patient relationship and that responding to email may also create a legal duty. Therapists who enable and respond to comments on blogs, or who reply to postings on Twitter should be mindful as to the potential for such responses to be read as prescriptive or advice-giving. Give thought to whether you wish to engage this level of clinical contact, along with the legal and ethical responsibilities that follow.

Also be aware that other risks arise when current patients use such forums to interact with you. These interactions may become a part of the patient’s legal chart. One way I address this is by outlining in my Social Media Policy that current clients should not use social media sites to interact with me, and that they should use the phone instead.

Responding to Interview and Guest Writing Requests

Getting your point across

Sometimes, someone who has read your blog or seen your Twitterstream may contact you to request your participation in an interview. You may be comfortable with print media but not radio or televised appearances. Anyone considering doing live, taped media appearances should should strongly consider obtaining consultation on managing media appearances. For any interview, request an advance list of the types of questions they plan to ask. This will help you prepare and collect your thoughts. Then make your own list of main points you want to be sure to address. This can help prevent the painful experience of later finding your well-intentioned thoughts misquoted or feeling that you missed an opportunity to get your message across.

Some people do email interviews which can give you the chance to be careful and thorough and edit your responses. But most print interviews still happen over the phone. Be attentive about not being led astray or talking about off-limit issues whether they be about your incomplete data findings or specific clinical examples that could reveal more than you intend. Many interviewers are sensitive and respectful to those in our profession, but some people may be persistent about digging for a story and you need to have good boundaries in such scenarios. This can be challenging to a media newcomer.

Some interviewers will provide you with a draft or your comments to review pre-publication and this is a good time to clarify if you feel you’ve misspoken. But many media sites will not grant you this opportunity, so you’ll want your first shot to be fairly focused.

Maintaining confidentiality and obtaining informed consent

Be extremely thoughtful when you are asked to share clinical examples. Some people may invite you to chat or write stories about your experiences with your clients. Prepare in advance for how you plan to respond. Consider what it will be like for any of your clients to read the story or interview later.

If you are invited to speak or to give a training to a group of professionals, be advised that many such lectures now get recorded, webcast, and tweeted. This means that you are no longer simply presenting to the group of people who is in the room with you, but your presentation may reach many people who you cannot see, and people may access it later.

Some clinicians believe that if you obtain a client’s consent, if you mask the identifying details, or if you show a draft of the writing to the client and let him approve it, it is permissible to share such clinical material with the media in certain contexts. Other clinicians are highly protective of what happens in-session. These clinicians believe that even asking for client consent or participation in the creation of such documents is intrusive and contaminating of the therapy process. It certainly could be perceived by some clients that your own media pursuits or desire for success are eclipsing your commitment to their clinical care. It pays to be prudent and to weigh clinical considerations before thinking about potential benefits to others or to your visibility.

If you do plan to regularly blog, tweet, or speak to news sources about any of your casework, you should first obtain informed consent from your clients. Clients need to be made aware that this is something you do and they should understand what your procedures are to ensure their privacy and confidentiality. You do not want your clients to be surprised to find any details of their work with you that you have been posting without their knowledge and consent, even if you are masking identifying information.

Providing commentary on public figures or news items

One opportunity media psychologists have is to educate the public about the ethics and responsibilities of our profession. Those of us providing outreach to the general public are frequently asked to comment on news items or public figures. I’ve had followers on Twitter ask for my professional opinion on celebrity behavior. Rather than ignoring these queries, I use such requests as chances to explain that I cannot ethically offer diagnostic impressions about people I have not assessed or treated. Further, I explain that when someone does utilize my services, their treatment stays confidential.

Responses of this nature can provide an important counter-example to many of the pop-psychology figures in the media. The public may get the impression that clinicians are delighted to offer diagnostic assessments of people they’ve never evaluated. We have to take care not to comment on such things and this can be a teaching moment for the public, about what we do and our ethical standards.

That said, we can, of course, offer general psychoeducational information to others, and there are often ways to reframe our responses to these questions so that we can provide helpful information to others.

Other issues related to client rights and dignity

Whose status update is this anyway?

Some people may believe that even on locked accounts, it is safe to blog or Tweet about cases.

Remember that friend networks are not consultation groups. Even without names, sex, or ages in a post, if you mention the presenting issue or even when the client has met with you, this can be enough detail to identify your client to others. It can feel particularly compelling to post status updates about challenging cases, crises and traumas, clinical successes, or strong countertransference feelings. Remember that you do not want people checking your feeds for mention of themselves, their acquaintances, or out of voyeuristic curiosity. While it may feel like you are simply sharing aspects of your life, remember that this is confidential clinical care and HIPAA violations are ethical breaches subject to up to $250,000 in fines or imprisonment.

This issue has gotten more press recently as there have been several publicized cases of HIPAA violations on social networking sites. In October, 2009, New England Baptist Hospital banned employees from using social networking sites due to concerns that hospital workers were sharing too much about patient care. In June, 2010, a San Diego county hospital fired five nurses for discussing patient information on Facebook.

This is a major emerging professional challenge as social networking increases and sites continue to encourage frequent sharing of daily activities. At the same time, providers continue to have vague notions about the reach of their postings and whether they are sharing aspects of their own day or their client’s day.

Conclusion

This article covered a basic introduction to some of the issues that can come up for clinicians venturing into social media. Having a social media presence can be a highly rewarding experience, but it does require thought and care. For more comprehensive information about media psychology, I recommend perusing the references below. Of special note is the McGarrah, et al, piece: In the public eye: The ethical practice of media psychology [pdf] which provides more in-depth information and is essential reading for anyone venturing into media psychology.

References

Behnke, S. (2008, April).  Reflections on media ethics for psychologists. Monitor on Psychology, 46-47.

McConville, C. Hospital cuts off use of Facebook. Retrieved June 12, 2010 from http://news.bostonherald.com/business/healthcare/view.bg?articleid=1204514

McGarrah, N., Alvord, M., Martin, J., & Haldeman, D. (2009).  In the public eye: The ethical practice of media psychology.  Professional Psychology: Research and Practice, 40, 172-180.

Recupero, P. R., Legal Concerns for Psychiatrists Who Maintain Websites. Psychiatric Services, April, 2006, Vol. 57. No. 4, 450-425.

Recupero P.R., E-mail and the psychiatrist-patient relationship. Journal of the American Academy of Psychiatry and the Law, 33:465–475, 2005 Retrieved June 15, 2010 from http://www.jaapl.org/cgi/content/full/33/4/465

Rutledge, P. What is media psychology? Retrieved, June 28, 2010 from http://mprcenter.org/?page_id=16

Stickney, R., Hospital will fire workers in Facebook scandal. Retrieved June 12, 2010 from http://www.nbcsandiego.com/news/health/Hospital-Fires-Emps-in-Facebook-Scandal-95794764.html

Wynn, P. (2010, January/February). Brave New World of Social Media: Social networking is transforming the way medical students communicate with one another, but is online content meeting professional standards? The New Physician. Retrieved June 12, 2010 from http://www.amsa.org/AMSA/Homepage/Publications/TheNewPhysician/2010/0110SocialMedia.aspx

© 2010 Keely Kolmes, Psy.D.

To cite this page: Kolmes, K. (2010) An introduction to media psychology for bloggers and tweeters. Retrieved month/day/year from http://drkkolmes.com/2010/06/28/an-introduction-to-media-psychology-for-bloggers-and-tweeters.

Email Tips for Clinicians

Nearly everyone uses email nowadays. I would guess anyone who is reading this right now has an email account. While many clinicians avoid social networking sites such as Twitter, Facebook, or LinkedIn they may still use email to keep in touch with family or to access email lists and exchange notes with colleagues.

Those who publish their email addresses with their office information are likely to see more clients using email as the point of initial contact, even if it is their intention to dissuade clients from using email as part of treatment. Some others may be comfortable with ongoing use of email as a way to quickly convey appointment changes to clients or even to send files or documents that are related to treatment.

If email has been or will be a part of your clinical practice, there are some important factors to consider.

Initial Contact

A new challenge for clinicians who are visible in social media is that many clients are obtaining clinicians’ email addresses and using them as a point of initial contact. Very often these emails may contain specific and extensive information along with requests for professional advice or information. Clinicians should be very careful in responding to such queries as their response can unintentionally initiate a therapist-client relationship. Giving any advice or offering diagnostic information can be perceived by a prospective client as beginning a treatment relationship. Sometimes the client sending such emails may reside in another state or another country and may not even be appropriate for our practice. I typically respond to such queries with a simple note. I also take care to delete the quoted text of the original email, in the event that someone else has access to it:

I am legally and ethically unable to provide psychological advice,
diagnoses, or assessments via email to people who are not my
patients.

If you have concerns you wish to discuss, you may wish to consider
contacting a therapist who lives in your area and scheduling an
appointment to discuss these matters with them.

Bear in mind that situations involving initial emails may be stickier if the individual sends information related to intent to harm self or others. Choosing whether and how to reply in cases like this should involve consultation and may entail locating crisis resources in the client’s location.

Software Security

Recent privacy flaps such as what happened with Google Buzz illustrated for me how important it is to use an encrypted and secure email address if you plan to exchange any email with patients. Digitally signed and encrypted email can be exchanged on sites like ciphersend or hushmail, and some offer secure forms that you can add to your website so that client data is protected. Be sure that this is the email address you put on your cards, website, and any public information. Also, if you are having mail notification sent to another email account to alert you that you have a message on a secure site, select the option that does not show the sender’s name/address in the forwarded mail. This ensures that you are not advertising secure mail and then having client data sent to a non-secure site which would be misleading.

If you have clients who want to use email to send you anything, have them come up with a password that you can use to encrypt each message. This can easily be included on your intake form. Each client should have their own unique password that only you and them know. Clients may also want to create their own secure address on one of these sites if they wish to bypass the password step and exchange secure messages with you.

If you are advertising use of secure email, and you use any web-based referral sites which mask your email address but allow clients to email you from the site, be sure you have linked all these business-related services to your secure email address to avoid security loopholes and being misleading to clients. Do the same if you use sites like PayPal or other credit card payment sites which are sending you information related to the people you treat. And be aware that email sent from data forms on these non-secure sites will compromise privacy. If you use any kind of VOIP messaging service which sends voicemail messages to your email account (sometimes with names/numbers attached to messages), also make sure you’ve selected a secure email address to which they are sent. In essence, clean up all of your various points of contact to be sure that all information related to clients goes to a secure account.

If you are someone who has used another email address with clients and you are transitioning to a service that offers encryption or more secure email, make sure you remove all client names and emails from your former email account so the names are not stored in your contact list. Remind clients to do the same for your old email address.

Lastly, it’s good to be cautious when responding to email from accounts where email was forwarded. Some sites, such as Google, have occasionally exposed the forwarded email address even when you have chosen reply to show  the originating address. If you are writing from an email address you’d prefer to keep personal, it may be safer to log out and log into the appropriate email account to respond to some messages.

Hardware Security

It goes without saying that if you are downloading emails to your computer or accessing them via a mobile phone, then you should at the very least be logging out of sites when you are done reading messages and using a password on your phone or computer at login or wakeup to prevent others from accessing these accounts.

Be aware that cellphones and laptops are frequently lost or stolen. Encrypting messages or other client data is an important way to protect any client data stored on these devices in the event of loss or theft. If you keep a separate laptop at work, don’t leave it on your desk after hours. Instead, store it in a locked file cabinet.

Be cognizant that we do not just have to be concerned about what happens on our end with messages to clients, but we should also be protective of what may happen on the client end. Even with protections in place, emails can be viewed by system admins or others in an office. If your client is in a public place and leaves her computer unattended, it is possible that anyone walking by may read your message.

Spouses or significant others may also have access to a client’s computer or cellphone which may contain email messages. This is another reason to keep disclosure of sensitive material out of emails, even when security measures are taken. A confidentiality notice in email is also a good reminder to clients about being conscientious about the use of electronic communication.

Social Networking Sites

Do not use the same email address you give your clients when you create accounts on social networking sites. You can post your practice email address publicly, but if you want to avoid popping up as a “suggested” friend or contact to your clients on these sites, create a different email address for logging into these sites. I also include in my own policies that clients who see or find me on such sites should never use the direct message systems on any of these sites to contact me, as they are not secure. Messages sent and received on these sites may also become a part of the legal record of treatment and may need to be incorporated into the client’s chart.

Shared Email Lists

If you are a member of any email list, there is the potential for one or more clients to also be on the same email list. These could be either personal or professional lists. Social circles do overlap, and cultural and community interests easily draw people together and make the world a smaller place. What this means on the Internet is that it is also very possible that you may discover you are on a shared email list with one of your clients or with others who know or are closely related to one or more of your clients.

Given these possibilities, you may have to choose carefully at times which email address you want to use and how much you care to disclose about your personal life on such lists. There are pros and cons for different approaches.

If you are using the email list for personal support, community, or socializing, you may prefer not to use your professional email account–but this opens up the possibility that your personal email may be discovered or shared with those you didn’t want to have it. On the other hand, sticking to your professional email address for all types of interactions on the Internet may make you identifiable as a clinician in places you’d prefer not to be identified, and you may not wish to publish personal things on the Internet with your professional name.

Some prefer one email address for all interactions while others feel that having a personal email and a professional email address makes for stronger branding and less blurring of personal and professional roles. Clearly, this is something to be thought through and your choice will depend upon your own comfort, as will the amount of personal sharing you’re comfortable doing on places where your messages may be accessed or archived.

Policies

It is appropriate to make clear and explicit policies for whether and how you use email in clinical care. You should put a statement about this in your policy forms. Clients should be informed about how long it typically takes you to respond to email messages, and they should be informed that email is not appropriate to communicate emergency situations to you. If you do not wish to have clients emailing you for any purpose, then do not put your email address on your website or business cards. If you allow email in specific cases, make this clear.

My own policy states that I prefer to only use email for business items such as changing appointments and it also notes that all emails sent and received are printed and placed in the client’s file. It should be noted that many practitioners feel that it is only essential to document emails that reference clinical material, and there are varying views and practices on whether administrative emails (e.g., schedule changes) should be documented.

Non-Confidential Exchanges

Some may prefer to continue to use non-secure email for professional exchanges that are non-confidential in nature, including listserv use, research, or exchanges with other clinicians. If you decide to use secure email, you can always retain less secure account for non-confidential exchanges. Just be careful not post or publicize this email address on business cards or other public listings and make sure your colleagues know not to give it out to clients.

References

Drude, K, & Lichstein, M. Psychologists Use of E-mail with Clients: Some Ethical Considerations. (2005) The Ohio Psychologist. Retrieved April 28, 2010 from http://kspope.com/ethics/email.php

Kolmes, K. (2010) Google Buzz alarms a psychotherapist. Retrieved April 28, 2010 from http://drkkolmes.com/2010/02/18/google-buzz-alarms-therapists/

Recupero, P.R. E-mail and the Psychiatrist-Patient Relationship. J Am Acad Psychiatry Law, December 1, 2005; 33(4): 465 – 475. Retrieved, April 28, 2010 from http://www.jaapl.org/cgi/content/full/33/4/465

Taube, D.O. (in press). Confidentiality for California psychotherapists (pp. 68 – 108).

Zur, O. (2010). I Love These E-Mails, or Do I? The Use of E-Mails in Psychotherapy and Counseling. Retrieved month/day/year from http://www.zurinstitute.com/email_in_therapy.html

© 2010 Keely Kolmes, Psy.D.

To cite this page: Kolmes, K. (2010) Email tips for clinicians. Retrieved month/day/year from http://drkkolmes.com/2010/04/28/email-tips-for-clinicians/.

In the coming weeks, I plan to create a similar page for the posts that are more specifically geared towards demystifying therapy for consumers.

At a couple of recent trainings, and in consultations with other mental health professionals, the question has come up about whether is is okay to check in on sites like Foursquare, Loopt, brightkite, and Gowalla when one is involved in the provision of clinical services. I have met with a few trainees who use these sites socially and who are eager to rack up points by checking in when they go to work at their practicum or internship sites to see clients. My predictably conservative take on this is that it is probably not the best idea.

It’s one thing for clients to decide on their own to add your clinic or private practice to these sites and, subsequently choose to check in when they attend therapy. But adding your own psychotherapy office or clinic to location-based social networking sites could be a walk down a slippery slope. It could be perceived as your encouraging clients to publicly check-in on these sites which raises a number of sticky issues.

When sites like foursquare encourage business owners to put their sites up to connect with their customers, they are usually thinking of bars, restaurants, or other non-confidential services. But when you put your own business on a site like this when you are involved in the provision of confidential services it’s a bit more dicey whether it’s simply strategic marketing and business promotion or an invitation for people to check-in. Given that ethics codes for psychologists, social workers, and marriage and family therapists all strictly prohibit the solicitation of client testimonials, might putting your psychotherapy practice on sites like this be perceived as a passive request for endorsement by clients? A trickier question is whether a “check-in” is the same thing as a testimonial. Maybe not, but it does seem to be some sort of indicator of patronage. We may not be realizing it, but our presence on these sites may be perceived as a veiled invitation for clients to disclose that they are in treatment with us.

I find myself wondering if particular populations or individuals are more likely to be lured by points and badges at the expense of their privacy. I can certainly imagine some adolescent clients going for the check-in before thinking twice. And if you work in outpatient treatment or see people multiple times a week, do you really want them to become the Mayor of your clinic? We may hope that distressed clients have more on their minds than checking in when they go to therapy, but one never knows.

Some might point out that putting your practice up on a site does not mean that you have identified who you have seen in your office. This is correct, of course. A client still gets to choose whether or not to check in when she attends therapy and the disclosure is hers to make. But the question remains whether the invitation alone could be perceived as subtly influencing some clients to do so.

These are questions about the gray areas of overlap between social networking and marketing of services. They stir up issues related to boundaries, ethics, confidentiality, and multiple roles. The APA Ethics Code applies only to activities that are a “part of (our) scientific, educational, or professional roles as psychologists.” The Internet has been already making it harder to distinguish the separation between our personal and professional lives. And certainly, once we have created a listing on sites to advertise our practices, we have brought our professional lives and the duties and responsibilities that come with it into another realm. It’s worth it to be mindful about which risks you want to take in your own professional practice.

References

American Association for Marriage and Family Therapy. (2001, July 1). AAMFT code of ethics. Retrieved from http://www.aamft.org/resources/lrm_plan/ethics/ethicscode2001.asp

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

National Association of Social Workers. (1999). Code of Ethics of theNational Association of Social Workers. Washington, DC: Author.

© 2010 Keely Kolmes, Psy.D. To cite this page: Kolmes, K. (2010) Location based check-in sites for mental health professionals. Retrieved month/day/year from http://drkkolmes.com/2010/02/26/location-based-check-in-sites-for-mental-health-professionals/.

Please note that since this original blog post, I have updated my Social Media Policy to include information about location-based check-ins and some other items not mentioned on this page. You are welcome to download the current document.

Other clinicians may copy, share, or adapt this policy to suit your own practice needs, but you may not use this work for commercial purposes. If you use my policy for training or educational purposes, please cite me as the original author.

Thanks to everyone who provided feedback on my first draft. I have slightly modified some sections and added a bit more to this document. I realized that some sections needed a bit more explanation so that clients would understand my rationale for my practice choices. When this policy is final, I will upload it to my forms page and print it up for current clients. As before, I invite anyone to copy or modify this form for their own practice.

This document outlines my office policies related to use of social media. Please read to understand how I conduct myself on the Internet and how you can expect me to respond to various requests and interactions between us.

If a time should come when I revise any of these policies, I will bring an updated copy of this form to our session so that you are aware of any changes.

If you have any questions about anything within this document, I encourage you to bring them up when we meet.

Friending

I do not accept friend requests from current or former clients. This holds true on Facebook, LinkedIn, and all other social networking sites. My reasons for this are that I believe that adding clients as friends on these websites can compromise confidentiality and blur the boundaries of our therapeutic relationship. If you have questions about this, please feel free to bring them up when we meet and I’m happy to talk more about it.

Fanning

I maintain a Facebook Page for my professional practice. I use this Page to allow colleagues to share my blog postings and practice updates within Facebook. All of these articles are also directly available on my website.

While you are always welcome to visit my Facebook Page and read or share articles posted there, I do not allow clients to become Fans of this Page. I believe having clients as Fans of this Page creates an even greater likelihood of compromised client privacy and I do not want others who may look through my list of Fans to find any clients listed. In addition, it is a violation of my professional ethics code to solicit testimonials from clients. I feel that the term “Fan” implies a request for a public endorsement of my practice.

If you are my client and I see that you have become a Fan of my Facebook Page, you can expect me to discuss this with you in-session and request that you remove yourself from my Page. If it will be awhile before our next scheduled meeting, I may remove you myself and I will discuss it with you during our next session.

Please note that you can subscribe to the page via RSS without becoming a Fan and without creating a visible, public link to my Page. You are welcome to do this.

Following

I currently maintain a professional Twitter stream. If you use an easily recognizable (to me) name on Twitter and I notice that you’ve followed me there, you can expect me to bring it up in therapy so that we can briefly discuss it.

My primary concern will be your privacy. There are more private ways to follow me on Twitter (such as subscribing using an RSS feed or using a locked Twitter list), which would eliminate your having a public link to my content. But you are welcome to use your own discretion in choosing whether to follow me. There is nothing I post here that I would not want you to see.

Please note that I will not follow you back.

I do not follow current or former clients on blogs or Twitter. If there are things you wish to share with me from your online life, I strongly encourage you to bring them into our sessions where we can process them together, during the therapy hour.

Interacting

Please do not use messaging on websites such as Twitter, Facebook, and LinkedIn to contact me. These sites are not secure and I may not read these messages in a timely fashion. If you need to contact me between sessions, the best way to do so is by phone. Direct email at drkkolmes [at] gmail is second best for quick, administrative issues such as changing appointment times. Please see the email section below for more information regarding email interactions.

Use of Search Engines

It is NOT a regular part of my practice to search for clients on Google or other search engines. Extremely rare exceptions to this may be made during times of crisis. If I have a reason to suspect that you are in danger and you have not been in touch with me via our usual means (coming to appointments, phone, or email) there may be a circumstance in which using a search engine (to find you, find someone close to you, or to check on your status) becomes necessary as part of ensuring your welfare. These are extremely rare situations and if I resort to such means, I will document it and discuss it with you when we next meet.

Google Reader

I do not follow current or former clients on Google Reader. I also do not use this account to share articles with current or former clients. I share many links of interest via my Twitter account, which you are welcome to read. If there are things you want to share with me that you feel are relevant to your treatment, I encourage you to bring these items of interest into our sessions.

Business Review Sites

There are a number of different websites including Yelp and Healthgrades, on which you may find my practice information. Many of these sites comb search engines for business listings and automatically add listings. If you should find my listing on these sites, please know that my listing on any of these sites is NOT a request for a testimonial or endorsement from you as my client.

The American Psychological Association’s Ethics Code states under Principle 5.05 that it is unethical for psychologists to solicit testimonials: “Psychologists do not solicit testimonials from current therapy clients/patients or other persons who because of their particular circumstances are vulnerable to undue influence.”

Of course, you have a right to express yourself on any site you wish, but due to confidentiality, I cannot respond to any review on any of these sites whether it is positive or negative. I urge you to take your own privacy as seriously as I take my commitment of confidentiality to you.

If we are working together, it is my hope that you will bring your feelings and reactions to our work directly into the therapy process. This can be an important part of therapy, even if you decide we are not a good fit. If you still choose to write something on a business review site, then please remember this is a public forum on which you could be sharing personally revealing information. I urge you to create a pseudonym that is not linked to your regular email address or friend networks.

Lastly, none of this means that you cannot share that you are in therapy with me wherever and with whomever you like. Confidentiality means that I cannot tell people that you are my client and my ethics code prohibits me from requesting testimonials. But you are more than welcome to tell anyone you wish that I’m your therapist in any forum of your choosing.

Email

I prefer to use email only to arrange or modify appointments. Please do not use email to send content related to your therapy sessions, as email is not completely secure or confidential. If you choose to communicate with me by email, please be aware that all emails are retained in the logs of your and my Internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. You should also know that any email I receive from you and any responses that I send to you will be printed out by me and kept in your treatment record.

Yesterday, I posted a draft of my Social Media Policy for Psychotherapy on this blog. I also included a link on Twitter. I made it clear that this was a work in progress and asked folks to feel free to comment or suggest additions. Of all the public and private feedback I received, the section of my policy that garnered the most criticism was the part about deleting clients who become “Fans” of my Facebook Page. I appreciate the feedback, and I may modify the language of this section to soften it a bit. I also need to add sections on use of pseudonyms by both therapist and client and on consumer review sites such as Yelp and Google and Yahoo Business.

Thank you to @susangiurleo and @TriBeCaTherapy over on Twitter for some different perspectives and for raising questions about how it might affect a client to be deleted as a “Fan” from a therapist’s Page. I certainly don’t want for a client to feel hurt or rejected. The very reason I’m creating a Social Media Policy in the first place–and discussing it with clients–is to minimize the potential for such feelings of rejection. I’m making it extremely clear that this policy is universal for all clients and not personal. I’m also explaining my rationale. I want this information to be clear and accessible before such events transpire so that it’s not a mystery as to how I’ll respond. Thus far, I haven’t ever been in a position to have to delete a client from my Facebook Page. I suspect that this is because I work mostly with fairly media savvy adults who care about their privacy. Most who have any interest in my social media presence know how to access it while still retaining their privacy. But this could easily change.

I was asked why I would even create a Facebook Page if I did not wish for clients to become “Fans.” Great question. First, I am fascinated by social media and I swim in it, explore it, teach and write about it. Other clinicians consult with me both in terms of creating and modifying their own social media presence and to better understand how clients may engage online. I also work with clients who live and breathe on the Internet. It’s fairly impossible to specialize in this arena without beta testing things now and then in order to understand how they work from the inside. I also wanted to experiment with Facebook ads (which I’m no longer using) to see if I found them effective for advertising my practice. My Page was one way to attract potential clients to my content, and ultimately, my website.

I initially had strong concerns about establishing a Facebook Page because I worried that my only “Fans,” would be friends and family members and this brought up concerns about my own privacy! And yet, these were the best people to help me first experiment with the Page. I do still have some friends and family members as “Fans” of my Facebook Page. But I now also have people as “Fans,” who are trusted colleagues, clinicians in other cities who I’ve never met, and others who do not practice psychotherapy who just found and appreciate my posts. My Facebook Page allows others to read and share my postings within Facebook, which is nice for those who don’t use RSS feeds, regularly read blogs, or use Twitter.

Back to those who did not like my position on declining to have clients as “Fans.” It was pointed out that clients are grown-ups and I should not be making this decision for them. This is a valid point, but it raises some issues. Grown-up (and non-grown-up) clients may think a lot of things are okay that don’t feel okay to me in my clinical practice. Some of those things might include socializing or exchanging casual emails between sessions or feeling less concerned about the state of my record-keeping. Yes, despite my own commitment to maintaining client confidentiality, my clients themselves can choose to reveal they are in therapy with me whenever and to whomever they choose. However, this does not relieve me of my ethical obligations regarding confidentiality, or grant me permission to solicit client endorsements.

Sure, my clients are grown-ups, but I am also a grown-up running a clinical practice, and as such, I also have a right (and a responsibility) to establish policies and procedures that feel appropriate to me. My Facebook Page is part of my business and I get to set up how I’d like to conduct business on that Page. If a client wishes to disclose their therapeutic relationship with me, they always have the right and ability do so on their own Pages, profiles, blogs, or accounts.

One person said that I should not deny clients the kind of access that anyone else on the Internet has access to which was interesting. However, I am not actually limiting anyone’s access to my professional practice content or information in any way at all. Every piece of this information is on a public Page and “Fans” and “non-Fans” have the same access to it. I’m neither blocking them from accessing the Page nor preventing them from reading anything my other “Fans” can view. They can still see it, read it, share it with others, save it, and so on. The only thing they are unable to do is publicly link themselves to my Page. I fail to see how this is hurtful to a client.

I am not a rock star. I do not need my clients to be my “Fans,” particularly on a site which already has an unstable track record in regard to user privacy. The way I see it, other than the positive interpersonal exchange (pride, recognition, and other warm feelings between client and therapist), the person who stands to benefit the most from getting clients as “Fans,” on their practice Page is actually the therapist. By not accepting clients as “Fans,” I’m taking a stand against cavalier privacy policies in exchange for lower numbers. I’m willing to forgo a few extra “Fans” of my practice on Facebook if the trade-off is that those who might be curious about my clients are being told unequivocally: “You will not find people on this Page who are in treatment with me.”

Hopefully, I’m not short-changing my therapeutic relationships of the positive interactions that can still happen off of Facebook and in my actual office when clients admit that they had a desire to “Fan” or link to me. Other clients simply make mention of my blog or Twitter postings that had special meaning to them and in this way we can together acknowledge their care and interest in my work outside of the therapy room without them having to publicly endorse my presence on a website. Clearly, a client doesn’t have to be a “Fan” or “Follower” for us to both find value in these exchanges and work with the transference privately, within the walls of my office.

The beauty of office agreements and policies is that we all get to craft policies that reflect our own unique beliefs and values as clinicians. If you have a different stance on social media, patient privacy, or clinical care, then by all means create a social media policy that works for you and your practice. It would delight me to see other mental health professionals sharing different policies and agreements so that these can be accessible to clients who would like to know about your specific rules and boundaries. It would also allow clients to self-select clinicians whose policies best match their own beliefs and values. I think it would also be useful to other mental health professionals crafting their own policies to see a variety of practices related to different clinical perspectives and theoretical orientations.

Of course, I am still welcoming commentary on my own Social Media Policy which I know will evolve along with changes in the Internet. So if you have feedback, please share it via email or on Twitter.

Update: June 6, 2010

As of April, Facebook changed the “Become a Fan,” button to a “Like” button. While the terminology of the action of endorsing a page has changed, my beliefs about the problems inherent with clients “Liking” your business page on Facebook remain the same.

© 2010 Keely Kolmes, Psy.D.

To cite this page: Kolmes, K. (2010) I’m not a rock star! (More thoughts on Facebook fanning). Retrieved month/day/year from http://drkkolmes.com/2010/01/26/im-not-a-rock-star-more-thoughts-on-facebook-fanning/.