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.

Please be aware of my upcoming training. And feel free to share the following announcement with anyone you think might be interested!

SFCP Community Members’ Professional Development Salon

The Web 2.0 Psychotherapist: The Therapeutic Relationship and Social Media

Some clinicians are hesitant about having a personal social media presence (e.g., Facebook, LinkedIn, Twitter) but are beginning to explore having a professional social media presence for their psychotherapy practices. The current APA Ethics Code does not explicitly address our activities on the Internet. What does it mean to be “transparent” using social media as a clinician? How might it influence one’s clinical work? What boundary issues do clinicians need to be aware of when they create an online social media presence? What happens when clinicians and clients cross paths in online spaces? Lastly, how can we think about this analytically and bring these new experiences of the relationship into the work?

Speaker:
Keely Kolmes, Psy.D., Dr. Kolmes is a psychologist in private practice in San Francisco who writes and speaks on the intersection of clinical care and social media.

Discussant:
Robert L. Friend, M.D., SFCP Member and Faculty

Moderator: Renée Spencer, M.F.T., SFCP Community Membership Co-Chair

Preparation
In preparation for the Salon, Dr. Kolmes suggests that attendees use Google or another search engine to search for yourself. Please use quotation marks around your name and search for yourself in various formats depending upon names you use on the Internet. For example, she would do the following searches on herself:
“Keely Kolmes”
“Keely Kolmes, Psy.D.”
“Dr. Keely Kolmes”
“drkkolmes”

Thursday, April 8, 2010
7:30 to 9 PM
San Francisco Center for Psychoanalysis
2340 Jackson Street, 4th floor Auditorium
San Francisco

Registration & Fees
This series is free to SFCP members, candidates, and community members. For others, the cost is $35 per meeting payable at the door. Attendance at the previous salons is not required.  Prior salons were recorded on DVD and can be borrowed from the library.  Pre-registration is encouraged but not required. RSVP to 415-563-5815 or to finance [at] sf-cp.org.

1.5 CME/CE credits (pending) for $15.00

The San Francisco Center for Psychoanalysis is accredited by the Institute for Medical Quality/California Medical Association (IMQ/CMA) to provide continuing medical education for physicians. The San Francisco Center for Psychoanalysis takes responsibility for the content, quality and scientific integrity of this CME activity.

PHYSICIANS: The San Francisco Center for Psychoanalysis designates this educational activity for a maximum of 1.5 credits as listed for each individual program, AMA PRA Category 1 Credit(s). Physicians should only claim credit commensurate with the extent of their participation in the activity. This credit may also be applied to the CMA Certification in Continuing Medical Education.

LCSWs/MFTs: The San Francisco Center for Psychoanalysis is a provider approved by the Board of Behavioral Sciences, Provider Number PCE623, for 1.5 credits on an hour for hour basis.

PSYCHOLOGISTS: Psychologists attending SFCP events approved for CME credits may report AMA PRA Category 1 Credit(s) toward their CE requirements and are now able to directly submit their verification letters at the end of each renewal cycle using the MCEP credit reporting form that can be found on the internet at: http://www.cpapsych.org/associations/6414/files/mcepaa/files/MCEP_Reporting_Form.pdf

REGISTERED NURSES: The San Francisco Center for Psychoanalysis is a provider approved by the California Board of Registered Nursing, Provider Number 02677, on an hour for hour basis.

SFCP is approved by the American Psychological Association to sponsor continuing education for psychologists. SFCP maintains responsibility for this program and its contents.

Course Objectives:
1) Participants will develop a basic knowledge of Twitter, LinkedIn, Facebook, and blogging and how they might be used as an adjunct to one’s practice.
2) Participants will learn how the current APA Ethics Code may be applied to Internet activities.
3) Participants will have the opportunity to engage in discussion about clinical boundaries and the potential impact of both therapist and client encountering one another out-of-session in online spaces.

Commercial Support: None

Faculty Disclosure: The following moderators and planning committee members have disclosed NO financial interest/arrangement or affiliation with commercial companies who have provided products or services, relating presentation(s) or commercial support for this continuing medical education activity: Keely Kolmes, Psy.D., Robert Friend, M.D. and Renee Spencer, M.F.T. All conflicts of interest have been resolved in accordance with the ACCME Updated Standards for Commercial Support.

Last Wednesday, I logged into Gmail to discover that I had a new little Buzz icon. When I clicked on it, I discovered what everyone was tweeting about: I was auto-following a number of people. Some I knew and some I didn’t really know at all. We just happened to be active participants on shared email lists, but we’d never met.  I’d heard the murmurs about Google Buzz, so I knew something was brewing. But what arrived wasn’t what I expected. I certainly wasn’t prepared for the invasive experience of having Google decide for me who I should be following based upon the frequency of our email exchanges. And this was just on my personal email account.

7. Of course, if you use PayPal or have a presence on other sites like Psychology Today on which clients may contact you, switch the email address to your new secure email.

Other resources

For some more Gmail privacy tips, lifehacker has a good post Top 10 Google Settings You Should Know About. Here is another informative post 3 Things You Should Know Before Using (Or Continuing to Use) Google Buzz.

© 2010 Keely Kolmes, Psy.D.

To cite this page: Kolmes, K. (2010) Email tips for clinicians. Retrieved month/day/year from http://drkkolmes.com/2010/02/18/google-buzz-alarms-therapists/.

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/.

Please note that this is currently a work in progress. There may be important things to add to this policy, but this is my first draft. If you have any comments or suggestions or think something is missing, please directly email me.

Also, anyone is welcome to use or adapt this form to your own practice. I know that many practitioners adopt different stances than my own when it comes to how they manage clinical care and their social media policy. Please consider making your own policies readily available to your clients so that it is clear and documented, even if your approach is to take it case-by-case.

Friending

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

Fanning

I maintain a Facebook page for my professional practice. I do not allow clients to become fans of this page because I believe there is an even greater likelihood of compromised client privacy and I do not want others who may look through my fans to assume you are my client.

If you are my client and I see that you have become a fan of my Facebook page, you can expect me to delete you as a fan and bring it up in our session when I see you next.

Please note that you will always be able to view all my Page content without becoming a fan or you can subscribe to the page via RSS without creating a visible, public link to my Page.

Following

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

My primary concern will be how it relates to your own privacy. There are more private ways to follow me on Twitter (such as subscribing using an RSS feed) 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 be aware 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

I do have a professional presence on Twitter, Facebook, and LinkedIn. I also keep a blog. You are always welcome to read my content on these sites if it is of interest to you. But please do not use these sites to send me messages or to interact with me outside of treatment. If you need to contact me between sessions, the best way is by phone. Email is second best, but only 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. 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, email) there may be a circumstance in which using a search engine to find another party close to you or seeing if you have or have posted to a blog, Facebook page, or Twitter may become necessary as part of checking on your welfare. These are extremely rare situations and If I ever resort to such means, I will definitely discuss this 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 and I encourage you to bring your own items of interest into our sessions if there are things you want to share with me that you feel are relevant to your treatment.

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.

The rest of the issue includes articles about online self-assessment on Google, blogger support communities, online therapy, and an analysis of treatment for Internet addiction. The issue also includes a Q&A on ethical, legal, and licensing issues in clinical work online, and a brief introduction to “the Net generation,” for clinicians unfamiliar with online life. So be sure to check it out if you are interested in clinical issues and digital life!

While I had been using Twitter socially since 2006, it hadn’t occurred to me to create a professional Twitter presence until just this year. In just a few months, I have been able to connect and engage with so many people around the psychology issues I’m most passionate about. It’s been an incredible resource for me and has allowed me to have so many interesting conversations and collaborations with people. In fact, I get so much out of it myself, that it’s very easy to forget that others find value in what I post.

If you’re a mental health professional who is interested in using Twitter, you may want to read my post Managing Twitter as a Mental Health Professional. Plenty of us are already there having conversations about mental health issues and we would love to connect with you.

Speaking of the others who are already connected on Twitter, I am especially delighted to be in such great company with the other top ten. If you’re interested in psychology tweets, you should definitely be following these folks too. Links to them are here and here.

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 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.

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.

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/.

Managing Twitter As a Mental Health Professional

Social networking is great. It can be fantastic for our clients in terms of finding support and connection. It can also be wonderful for those of us who want to market ourselves or network with other professionals. It can even be good for us in the same ways it is for our clients: connecting us with friends or family members, and helping us to find our own support. However, there are also risks related to social networking for mental health professionals, and it is wise to carefully consider how you want to utilize social networks before plunging right in.

Professional vs. Personal

Any mental health professional considering joining a social networking site should first consider each network you wish to join and then develop clear goals, as to how you think you’d like to use them. One of the biggest risks of social networking for therapists is getting into sticky situations expressly discouraged by our ethics codes (i.e.– dual relationships, confidentiality breaches, and other boundary issues) when you do not clearly define for yourself whether you are using a social network as personal or business space.

So your first step when creating an account on a site like Twitter is to consider whether this space will be a place for you to market your business, or a place for you to interact with your friends. If you want to have both (and I believe we all deserve to have both!) I am a strong advocate for making two separate accounts for the two different purposes. If you are going to do this, be sure to use separate email accounts for the separate accounts you create on each network to minimize the possibility of work contacts and clients finding your private account and vice-versa.

Developing a Professional Presence

So now that you’ve opted to create a professional Twitter account, how do you manage it? When I am logged into Twitter as drkkolmes, I consider all of my actions and interactions to be part of my professional role as a psychologist. My professional Twitter account, like my professional blog, is an extension of my business identity. I am aware that I can be Googled by potential clients, current clients, past clients, employers, family members, or old school friends. I take great responsibility for what I post and consider it to be a part of branding myself as a serious professional.

To be blunt, I don’t use my professional Twitter account to post whether I’ve eaten a delicious sandwich, have walked my dog, or am off to meet a friend for tea. These are fine things to Tweet about, and, trust me, nobody loves raving about her food more than I do. But it is my opinion that these Tweets are more appropriate for a personal Twitterstream than a professional one. I recommend that you not use your professional stream to broadcast what you’re doing, when, or with whom. If you do wish to create a private Twitter account to share these kinds of personal tidbits, I recommend using a non-professional email address and locking your account so that it is friends-only.

Friending and Following

Some people believe that you should follow back anyone who starts following your Twitterstream. But when I am on a social networking site with my professional hat on, I am selective about who I friend and follow. On Twitter, I do not follow clients, and I do not follow friends. If you want see what you’re friends are up to, or you want to post personal updates, then by all means, create a private, personal Twitter account.

Why do I feel you shouldn’t follow clients? For a few reasons. First, it can easily compromise confidentiality by making visible a professional relationship. Second, it may invite clients to interact with you on Twitter in a non-secure medium (people you follow can direct message you on Twitter’s less-than-secure platform). If this were to happen, it brings into question whether or not these interactions become a legal part of the client’s records. Third, it brings into question clinical issues related to whether you are expected to pay attention to their updates and discuss these Tweets in treatment (and what if they Tweet that they are feeling suicidal?). Fourth, I want to use Twitter to receive professional updates about the field of psychology–not to get information about my client’s lives, which I prefer to hear about in-session.

This is also a good time to mention that I actively discourage clients from following me on Twitter. If I happen to recognize that a client has followed me, I wait and bring it up in-session. I talk a bit about my concerns about their privacy and I will suggest that they subscribe to my RSS feed rather than following me. It’s not that I don’t want a client to see my Tweets. It’s that I want them to be aware that having an online link to me could potentially lead to someone guessing that might be my therapy client. Some may decide this feels okay and continue to follow me anyway, but I think that at the very least, it’s worth a conversation. This conversation also allows for us to acknowledge the impact that it can have on the therapy relationship when it moves out of the room and into cyberspace. It also opens the space up for us to return to this, in the future, if needed.

Who will I follow on Twitter? Mainly other mental health professionals. But not just any mental health professional and not just anyone who follows me. You, of course, need to decide who provides valuable information to you. What I am looking for on Twitter is to engage in professional conversations, to obtain mental health news, and to connect with others who are thinking–and posting–seriously about mental health concerns as they relate to technology and social networking.

Sometimes, I may start following another therapist on Twitter, but if I discover that she’s mostly posting about her own personal emotional struggles or what song she’s listening to on the radio, I usually will stop following her pretty quickly. This may seem cold, especially for folks who are used to negotiating and communicating about relationships. But again, it comes down to weeding out the information that’s not useful to you. If someone is not adding relevant news or information related to what you are looking for on Twitter, you don’t have to feel apologetic for un-following them. There are plenty of followers to go around!

Once you’re following more than 30 or so folks on Twitter, that can be a lot of information to scan through, and it can be easy to miss the information that is most meaningful to you. Your mileage may vary, of course, but make sure you are following people who post information that is useful and interesting to you as a professional. And, feel free to re-evaluate and modify your Follow list over time. This is also where Twitter lists can become useful. You can organize people you want to follow into lists and this can help manage the stream. There are also a number of Twitter apps (or tools) that can help you manage and track the people you follow.

Some Clinical Cautions

Of course, it goes without saying that whether you keep a public or private account, mental health professionals should avoid Tweeting about any clinical material that comes up in therapy sessions. Even if you mask identifying data, avoid names, or generalize, it can feel incredibly exposing to a client to come across a Tweet about something that happened with them in your office. It is also easy to assume that those who follow you do not know your clients, but that’s a dangerous (and oftentimes erroneous) assumption.  Just don’t do it. Your clients will be happier and you will be protecting your practice.

Also be aware that even if you only Tweet about professional issues and news, some clients may experience it as very un-containing simply to see you existing outside of the therapy room in online space. It can be irrelevant to some clients, but others may find it discomforting and you should be prepared to engage in conversations about it. In addition, be mindful that even if you are only Tweeting professional updates, you are still revealing information about your habits, your schedule, and when you are awake at night by what and when you Tweet. If you do choose to use Twitter to also post personal Tweets, again, be aware of how this could impact your current clients.

It is also good to be aware that you are not only making yourself visible to your actual clients, but to other people in their lives who may know they are in treatment with you. This could be friends, partners, and family members. So be aware that you are choosing to make yourself visible in the world in a way that may potentially have an effect on your clients’ relationships and the perceptions of others in their lives about you and your practice.

If you have emailed at any point with your clients with the email address you use to create your Twitter account, you should be aware that you may come up in your client’s search when they look for “friends,” on the Twitter site, and vice-versa. It is very easy to accidentally, with a click of a button, auto-follow everyone in your address book. So be careful of this and also recognize that a client may follow you accidentally through this feature, and vice-versa.

Twitter Faux-Pas

How can you muck up your professional Twitter profile? Don’t interact with others or respond to questions. One of the lovely things about Twitter is that you can interact with many people. If someone posts a question that draws you in or is relevant to the work, by all means, reply. One of the things I most love about Twitter is that you can still participate in conversations with folks on Twitter, even if you are not formally following them. I peek at lots of posts and conversations Tweeted by people I’m not regularly following. I also review my own @replies often and can see if someone has asked me a direct question. I can easily @reply back without having to follow the person if they do not regularly post updates of interest to me.

Another thing you can do wrong on Twitter is post questions and then fail to acknowledge those who responded to them. If you are putting out questions to the Twitterverse, by all means let folks know you have seen and appreciate their responses. Otherwise, it can feel very one-sided and people may stop responding to your questions since you don’t seem really engaged in a real exchange. In that same vein, be careful of only using Twitter to promote yourself. I’ve seen some people whose only Twitter posts are their blog updates or news about their businesses. Even worse, is making your Twitterstream consist solely of automated blog feeds. This becomes tedious very quickly. Anyone can RSS to your blog feed if they are interested, but if you are using Twitter, then make it interactive. Rave about someone else’s site or link to useful information that others have provided. Share and promote others. It will come back to you.

Time to Tweet

If you’ve been itching to get onto Twitter, go for it. Post some questions, link to some articles, and if you have a website or blog, let folks know when you update it. If you see someone posting something that you like, Retweet it (you do this by posting RT @theperson’s name and add the link they posted). Of course, feel free to join and just observe for awhile. It’s okay to follow people and think for a bit about what you’d like to say. Nobody’s going anywhere.

So now it’s time to Tweet! Be cautious, but have fun, and start connecting. There is a lot of good information to find and share, and there are a lot of potential relationships to build.

© 2009 Keely Kolmes, Psy.D.

To cite this page: Kolmes, K. (2009) Managing Twitter as a mental health professional. Retrieved month/day/year from http://drkkolmes.com/2009/05/04/managing-twitter-as-a-mental-health-professional/.