Earlier this week, a colleague brought my attention to a contest that was being run on Goodtherapy.org. The contest invited participants to compete for six months of free weekly therapy sessions with the therapist of their choice. Participants entered the contest by posting a public comment sharing the following information:

• What are the obstacles currently preventing you from being able to receive or afford therapy?
• Why do you want to go to therapy and what issues are you facing or problems are you experiencing?
• How would you like to benefit from therapy and what are you hoping to achieve?

Top entries were going to be chosen and then the winners would be selected by having readers vote on the one most deserving of the prize of free therapy. While I appreciate that many people find it empowering to use Internet forums to write about the issues they struggle with, having such comments used as a way vie for the prize of “most worthy” of psychological care, as voted by readers, was objectionable in a number of ways.

A number of mental health professionals, including DeeAnna Merz Nagel and others who focus on clinical ethics,  posted comments expressing concern that this contest was exploitative of vulnerable populations and would violate many clinical ethics codes. The initial response from the website was to say that as a referral service, they were exempt from having to adhere to ethics codes. They also noted that names and emails were anonymous in the blog comments, offering participants a layer of protection.

Nevertheless, a couple more comments were posted by concerned practitioners, including myself, stating that we thought the contest was not offering appropriate protection to vulnerable people and that having readers vote on who was worthy of the grand prize was, at the very least, in poor taste.

After just a few days of commentary, Goodtherapy.org responded by removing the public comments (entries) from the blog and deciding not to allow users to vote on stories to pick the winner. Winners will now be selected by GoodTherapy.org.

I am grateful to those who spoke up and left comments expressing opposition to the format of the contest. But I especially wish to commend GoodTherapy.org for their thoughtfulness and care in reflecting upon the objections raised. They demonstrated sensitivity and flexibility in revising the competition so that it does not expose people who are in great need.

I’m so very pleased and excited to announce the launch of Without My Consent, a project on which I sit on the Advisory Board with a fine group of Internet superheroes. This project was co-founded by Erica Johnstone and Colette Vogele.

Without My Consent is intended to provide resources and information to victims of online harassment to help them find safety, seek justice, and stand up for their rights. We also hope to provide psychological resources for people who have been harmed.

It is also our hope that our site serves as a deterrent to those who may be thinking of doing harm to another individual. These individuals may wish to seek help to process the intense or disturbing feelings that might lead them to want to lash out against another person in such a way.

This project was recently mentioned on June 2, 2011 in The New York Times story How to Unmask the Internet’s Vilest Characters. This article discussed one of Without My Consent’s strategies: encouraging victims to file suit pseudonymously.

Keep your eye on us. There will be some interesting news and updates coming soon.

I am home after presenting for a second time at SXSW Interactive this week. This year, SXSW included a Health track which was a great addition to their programming, and of course, it made my annual trek even more meaningful. I was delighted to be able to attend more health panels this year and to meet up with more psychologists this year (in addition to long-time attendee, John Grohol, Psy.D., who has been my sole SXSW mental health pal for the past three years).

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

Groupon and Other “Deals” for Mental Health Professionals

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.

The website OnGoodAuthority is featuring a new CE course called Facebook and Google and Twitter…Oh My! Ethical Issues for Clinicians.

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:

Therapist-Client Interactions on the Internet

Thank you to everyone who participated in our survey. The summary of the results of the research Dan Taube, J.D., Ph.D. and I conducted on psychotherapists who have had intentional and accidental extra-therapeutic encounters with their clients on the Internet are posted on my research page. A larger slideshow can be viewed here.

To read a brief lit review and description of the research, please see our article Clinical implications of therapist-client interactions on the Internet: Boundary considerations in cyberspace.

I am very pleased to announce that the my online Continuing Education course in partnership with the Zur Institute is finally live!

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.

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

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.

I have been getting frequent requests for certain archived blog posts on Social Media for therapists. As a result, I’ve decided to compile them on a separate page. I will continue to blog here, but I am launching a new page: For Clinicians Using Social Media on which I will summarize all of the posts for mental health professionals as separate chapters. This page will always be accessible from the top of my main blog page.

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

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

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/.