To Accept or Not to Accept?
How To Respond When Clients Send "Friend Request"
To Their Psychotherapists Or Counselors On Facebook, Linkedin, Twitter Or Other Social Networking Sites
By Ofer Zur, Ph.D. & Azzia Walker, B.A.
This article is part of an online course: Digital Ethics for 8 CE credits.
Modern digital and Internet technologies have not only proliferated across the globe, but also have raised many complex clinical, ethical, and legal issues for psychotherapists, counselors, social workers, psychiatrists, administrators, and other mental health care providers, as well as for clients, patients, and other consumers of mental health services. Barnett (2010a) has appropriately titled his recent article on the topic, "Psychology's Brave New World: Psychotherapy in the Digital Age." The exploration of the intersection of digital technology and psychotherapy is in its infancy. Some of the issues being explored include e-mails between therapists and clients (Zur, 2008a), clients Googling their psychotherapists (Kolmes, 2010a; Zur, 2009), psychotherapists Googling clients (Grohol, 2010; Kolmes, 2010a, Zur, 2010a ), therapist self-disclosure (Barnett, 2010a,b; Keller, et. al. 2010; Lehavot, 2009; Younggren, 2010; Zur, 2008b, 2009). issues of confidentiality and privacy in the digital age (Kolmes, 2010a,b; Younggren, 2010; Younggren & Harris, 2010, Zur, 2009), and concerns with the digital divide, most commonly experienced between older psychotherapists and younger psychotherapists and between older psychotherapists and their younger clients (Zur & Zur, 2010). This paper is one more step in the preliminary exploration of these new, exciting, and complex territories. It is an invitation to contemplate and wonder about these matters, rather than prematurely proposing rigid rules and restrictions. More specifically, the main goal of this paper is to explore the complexities of online social networking, such as Facebook, LinkedIn, and Twitter, as they relate to psychotherapy and other mental health services.
Online Social Media Sites and Psychotherapy
Social networking is one of the most common forms of communication in the 21 st century. With over 500 million users of Facebook in 2010 (Facebook, 2010), inevitably, increasing numbers of psychotherapists also have profiles on Facebook, LinkedIn, or accounts on Twitter or other social networking sites. As is the case for many professionals, some psychotherapists' profiles are personal, while others are strictly professional. For those therapists who have personal information on their profiles, some include detailed personal information while others give the bare minimum. Some therapists use privacy settings to protect their personal information, while others do not. Those who do not use the privacy settings do not because they either do not know about these options, do not know how, or do not understand what other people can see or not see on their profiles. Increasing numbers of psychotherapists post a profile on Facebook as part of their practices with the primary purpose of professional networking and marketing efforts (Bavonese, 2010). One may argue that posting a standard website, online social networking profile or Facebook page is a must for a modern-day clinician. This argument is logically based on the simple fact that all successful 21 st century businesses, from Toyota, to GM, and online psychics to local pet stores and car mechanics all have an online presence. The majority of modern-day consumers search for services they need, including mental health services, online. They value information from fellow users on sites such as Yelp.com as much as they would trust the opinion of a close friend. Regardless of whether the original source of referral to a psychotherapist came from a colleague, friend, physician, or from an online search, consumers are likely to review the website of potential therapists and look them up on professional sites, such as psychologytoday.com or goodtherapy.com. Modern-day consumers put increased value on transparency, or more specifically, digital or online transparency (Barnett, 2010a,b; Zur, 2008b). Prior to calling or interviewing their potential psychotherapists, consumers are likely to search for the therapist's Facebook profile or page, or other social networking profiles (Zur, 2009).
In spite of the immense popularity and the proliferation of social networking sites, many psychotherapists, counselors, social workers, and mental health clinics and departments have been slow to cultivate a full, interactive online presence. This also occurs in the face of obvious professional and economic benefits. Along the same lines, psychotherapists, mental health departments, psychiatric hospitals, graduate school instructors, and ethicists all struggle to understand the implications and effects of online social networking on psychotherapy and other mental health services. Most mental health professionals are at a loss as to how to adapt their practices to the modern, digital reality. More specifically, many - if not most - psychotherapists and counselors cringe at the idea and dread the moment when a client presents a Facebook Friend Request. They wonder whether it is ethical to accept such a request, and they are concerned with the clinical and relational ramifications of ignoring it.
Psychotherapists, counselors, clinics, and mental health departments who consider posting a profile on social networking must be educated and knowledgeable about the technical, cultural, professional, clinical, ethical, and legal complexities involved (Barnet, 2010a; Grohol, 2010; Keller, et. al. 2010; Kolmes, 2009; Younggren & Harris, 2010) Whether using their own staff or using consultants and experts, they must have a good grasp of the general digital landscape in which social networking operates. They must attend to professional issues, such as professional presentations and marketing, and ethical issues, such as confidentiality and potential multiple relationships. They must consider posting a Facebook page in addition to a Facebook profile and understand the differences between the various social networking options.
This article identifies some of the most important questions surrounding the relationships between social networking and psychotherapy, discusses important issues of confidentiality, clarifies some of the confusion regarding what constitutes dual relationships, and proposes some ideas to guide psychotherapists and other mental health practitioners and administrators in their decisions regarding social networking.
Questions for Psychotherapists to Consider Before Responding to Clients' Friend Requests
Once a therapist, clinic or mental health department has posted a social networking profile or page they are likely, sooner or later, to face a Friend Request. Following are some areas of concern or questions that psychotherapists and administrators have to attend to when they face a Friend Request from a client:
What is on the Facebook profile? A profile that is strictly professional should be considered differently than a highly personal profile with family pictures, vacation videos, notes from a lover, photographs from a party, etc.
Does the therapist have a Facebook Page or only a Facebook Profile? Having a Facebook Page can reduce many potential problems for psychotherapists in regard to self-disclosure and other areas. Whether the therapist is an author, a presenter, a group leader, runs a center, etc. the Page can cover all of these areas in addition to the clinical practice. Unlike a personal profile, the Facebook Page is for professional interactions and, for the most part, is respected as such. The 2014 ACA Code of Ethics introduced a requirement that Counselors keep professional and personal pages separate. The Facebook Page is perfect for this requirement.
Does the therapist use privacy controls to control access? Psychotherapists can segment the list of "friends" into Limited Profile, Personal, Family, Business, and Client contacts, to name a few. In this way psychotherapists can post things that pertain only to one group and control the postings that each group can view. As was accurately noted repeatedly in the general media, Kolmes (2009, 2010a), Younggren and Harris (2010), and many others, privacy settings do not always provide the privacy they purport to protect. When one adds a client to a list, such as Limited Profile, accepting a friend request from a client does NOT have to mean they get unfettered access to the clinician's or clinic's profile.
What can a client view on the therapist's profile? It is important to be clear about what clients may be privy to on one's social networking site. Therefore, it is essential for therapists to understand how privacy controls work and how to add friends to lists such as Limited Profile before they consider accepting a Friend Request from a client. Therapists can decide what friends on various lists can see. Obviously, using the privacy control is extremely important if psychotherapists have sensitive information on their profile. These controls also help psychotherapists determine how their clients can communicate with them on the site (write on your wall, message, etc.). If one is unsure of what a client can see once they were added to a given list, one can use Facebook's privacy test of typing the friend's name and finding out what your profile looks like from their point of view.
What is the Context of Therapy? The context of therapy includes a set of factors that can help determine what is appropriate or inappropriate, clinically beneficial or not, ethical or not. The context of therapy includes client factors (i.e. diagnosis, age, culture, relationship to technology), setting of therapy (i.e. private practice, clinic, hospital, prison), therapeutic relationships (i.e. trust, distance, warmth, power differential), therapeutic approach (i.e. CBT, humanistic, feminist, eclectic, psychodynamic); and finally, therapist factors (i.e. training, age, relationship to technology, comfort with self-disclosure).
Who is the client? Is the client a high-functioning fellow professional or a very disturbed person? Does this client need clear limits or can he or she benefit from a more flexible approach?
Why did the client post the request? Younger clients, or what are sometimes called "digital natives," often have very different attitudes towards Internet disclosure than many (mostly) older psychotherapists. They often fall into the "reluctant adopter" category within the "digital immigrant" group. Younger clients may post Friend Requests routinely, without a second thought, as they are friends on social networking sites with almost everyone they know. and often people they don't know in person.
What is the meaning of the request? Is the request a routine action by a "Digital Native"? Is the request another manifestation of the client's tendency to push boundaries or to be intrusive? Is making the link between therapist and client public a way to take health view of the connection and de- pathologizing the therapeutic work? Is the client seeking more meaningful and deeper connection with the therapist?
What is the nature of the therapeutic relationship? Intensive or psychodynamic psychotherapy may merit different responses to a friend request than family therapy, short-term behavioral therapy, group therapy, or individual intermittent-long-term therapy, where a therapist sees the client once or twice a year over a period of several decades.
Where is therapy taking place? Does the therapy take place in a private office, home office, community mental health, or prison setting? Each setting may have a different bearing on the question. A friend's request from intermittent long-term therapy with a colleague will be viewed differently than such a request from a highly paranoid new client.
What is the community location of therapy? Does the therapy take place in a small and isolated rural community where everyone already knows everyone else's business anyway, or is it in a more anonymous metropolitan-urban setting?
What does being a friend with this client mean for the therapist? Psychotherapists must explore their own feelings, wishes, and counter-transference reactions to the client, his or her Friend Request, and to technology.
What is the potential effect on other potential clients? Current, past, or potential clients may be or may become your online friends or your clients' friends. People often get to know each other online, including through the profiles of other friends. The level of interaction you allow your clients to have on your site will affect the possibility of their getting to know your other friends. If you are going to make your friend list public (the default option on most sites), you must consider the collateral effect of your connections.
What are the ramifications of accepting a friend request from a client for confidentiality, privacy, HIPAA compliance, and record keeping? Obviously, this is one of the most important considerations in determining whether to accept a friend request or not. This question is explored in the section below on "Confidentiality and Social Networking."
Does accepting a Friend Request automatically constitute dual or multiple relationships? As the section below on dual relationships explains, accepting clients' Friend Requests may or may not constitute dual relationships. If the acceptance is likely to create dual relationships, then therapists must evaluate whether such dual relationships are ethical or clinically advised.
How might the therapist's response to a friend request affect treatment and the therapeutic relationship? As with most other types of boundary crossings and dual relationships, psychotherapists must consider the potential benefits of accepting or not accepting clients' friend requests as well as the potential risks. Psychotherapists should think through whether accepting clients as online friends is reasonably likely to cause harm, exploitation, loss of objectivity, or loss of therapeutic effectiveness. The 2014 ACA Code of Ethics added a new requirement that counselors avoid "personal virtual relationships" with clients. The precise meaning of this is unclear, but would likely include creating "friend" relationships with clients on the clinician's personal social media profile(s).
Confidentiality and Social Networking
One of the most important and relevant issues evoked by the use of online social networking in conjunction with mental health services is that of privacy and confidentiality of communication between psychotherapists and clients. Following are some general facts and ideas regarding confidentiality and social networking:
Issues of confidentiality are not likely to be relevant when psychotherapists use a 'passive' website, or what is called "business card" type website, describing their practice and expertise. This does not include a blog with comments enabled or any other form of audience participation. The reason that this kind of 'passive' website does not pose any concern with confidentiality is because they do not allow for viewers' feedback, comments, or responses. They are like a bulletin board, strictly a one-way communication.
Unlike a passive website, Facebook, Twitter and LinkedIn are interactive-indeed, they are social networking sites. These active, interactive forums require much more care and attention regarding the confidentiality and privacy of the therapist-client communication.
Younggren and Harris (2010) appropriately raised an important concern regarding confidentiality issues and social networking sites. They state: The maintenance of confidentiality is the first risk management issue raised by this type of communication. Most state laws require that psychologists maintain confidentiality. That is, they must be sure that the information that is shared with them by clients, including that person's identity, remains confidential unless the client authorizes the release of that information. This requirement could easily be violated through the use of a website designed for social networking. For example, if one were to accept a request to become a friend of a client on Facebook, the issue of the possible exposure of that client's identity to others must be addressed. In addition, just what information will be exchanged should also be addressed, because others might be privy to a client's confidential information. (p. 11)
Some psychotherapists, clinics and MH departments have elected to use a Facebook Page rather than a profile. Generally, Pages are used for businesses, celebrities, bands, or public figures. A Facebook page, unlike a profile is composed generally of one-way relationships with those who "Like" the Page or the business. The use of pages for marketing and promotion purposes is likely to grow in the next few years.
For a quick tutorial: Zur Institute's Facebook Page . Feel free to experiment by clicking "Like," post a comment, read other people's postings, etc.
When creating a Facebook Page, practitioners are likely to keep the information on the Page strictly professional and employ privacy settings for the profile, which may include more
A Facebook Page still presents several dilemmas. Kolmes (2010b) explains: The biggest problem with having a Page is that you will still have to decide how you feel about who Likes your practice. Will you want your family members listed on that Page for others to see? Will you accept current or former clients as people who endorse your Page? Having or allowing your clients to be connected to your public professional profile brings up issues of confidentiality. ("Pages vs. Profiles" section, 1 st para)
Even on a professionally-oriented Facebook Page, clients-fans can Like the page and therefore join the page and post on the wall. Then, a client may post a therapy or lineally related notes, which could be not only awkward for therapists and other fans but also, in fact, troublesome in regard to confidentiality, privacy, and HIPAA compliance.
If therapists, clinics, or mental health departments start a Facebook profile or Page, it is suggested that one weigh the pros of interaction and exchange of ideas with the possible con of fans misusing their access to post confidential communication that can be viewed by others. How one may decide what access fans will have will largely depend on the factors described in this article.
Additional complexities of clients posting on therapists profiles and pages are the issues of record keeping (Younggren & Harris, 2010). All psychotherapists' communication with clients on social networking sites regarding scheduling, clinical or other matters are not only confidential but also may be considered part of the clients' clinical records. As such, they may have to be documented in some form in the client's file. The complexities of these issues have been discussed in more detail by the first author (Zur, 2010b).
Generally, public communication between psychotherapists and clients on online social networking, such as wall posts and status update comments, can be accessed by "friends" and potentially many others, such as those in a shared network. On some social networking sites, such as Facebook, the access of friends and people of shared networks to one's wall and other information can be controlled through privacy settings. Similarly, psychotherapists can create a private lock in their Twitter accounts, and people will have to request to follow them, after which psychotherapists may grant or deny access.
When it comes to privacy, psychotherapists and administrators must know the distinction between public (wall posts, responses to status updates) and private (private message) communication. However, even private communication - as we know from past, widely reported, Facebook privacy breaches - is not foolproof. Security - online and offline - never is. Most experts agree that e-mail, which is not free of vulnerabilities either, is a more secure mode of communication than social networking sites.
Legally speaking, Dr. Younggren (2010) clarifies that communications between psychotherapists and clients through electronic means, like Twitter and Facebook, are "arguably not confidential." He also argues that these types of communication are likely to be completely discoverable and in no way protected by privilege.
It has become clearer in recent years that Facebook privacy can be compromised in many ways. First, privacy settings can be confusing and change regularly. People may not understand who can see what information on their profiles. In addition to this, there are hacker problems in which people illegally move past privacy settings and access information without authorization. And finally, there is a new area in which Facebook privacy can be compromised: by court order. There are a growing number of cases where courts have decided that, under certain circumstances, Facebook information must be disclosed. More info
It is important to note that the Facebook website makes the following disclosure: Although we allow you to set privacy options that limit access to your information, please be aware that no security measures are perfect or impenetrable. We cannot control the actions of other users with whom you share your information. We cannot guarantee that only authorized persons will view your information. We cannot ensure that information you share on Facebook will not become publicly available. We are not responsible for third party circumvention of any privacy settings or security measures on Facebook.
Clients must be informed about the concerns and issues surrounding privacy and confidentiality in regard to communication via Facebook, Twitter, and other social networking sites. This is similar to the disclosures that psychotherapists must have in regard to e-mails. (More specific ideas for informed consent are outlined below.)
In summary, before setting up your social networking profiles on Facebook, Twitter and the like, become informed about the confidentiality and other relevant issues, seek consultation, and when necessary, provide clients with informed consent. Above all, proceed with caution into these new and largely unexplored digital frontiers and keep yourself updated on developments in the field.
Social Networking & Dual Relationships
Dual relationships or multiple relationships in psychotherapy refer to any situation where multiple roles exist between a therapist and a client. The question of whether accepting a Friend Request on a social networking site constitutes dual or multiple relationships, or not, has been raised by several ethicists and professionals. The general answer to this question is that sometimes accepting a Friend Request on a social networking site from a client constitutes a dual relationship or multiple relationship, and other times it does not. Whether or not accepting the request constitutes a dual relationship depends on what kind of information clients are privy to and the nature of the therapist-client online interaction. Following are descriptions of both possibilities:
In many cases a client making a Friend Request on Facebook is asking the therapist to engage in a secondary social or professional relationship in addition to the therapeutic one. If the therapist accepts the Friend Request and allows the client to be privy to personal information on the profile and to post comments of a personal nature, this constitutes a social multiple relationship. Similarly, if the therapist accepts the Friend Request and allows the client to post comments of a collegial or business nature, this also constitutes a professional or business dual relationship. Obviously, the next question is whether a therapist should or should not engage in a Facebook-type social dual relationship with a particular client. It is important to reiterate, what psychotherapists should know by now, that dual relationships are NOT unethical, per se. According to almost all major professional organizations codes of ethics (e.g. APA, NASW, ACA), acknowledging multiple relationships is neither always unethical nor always avoidable. They assert that multiple relationships should be avoided if they could reasonably be expected to impair the therapist's effectiveness or cause harm. Whether dual relationships are clinically advised or are ethical or not is primarily determined by the context of therapy, described earlier on in this article.
Digital Natives and Digital Immigrants - Digital Divide & Ethical Divide
One of the biggest factors that determine therapists', ethicists' and other professionals' attitudes and clients' expectations are their relation to technology. In most general terms the younger generations, generation X and those who were born after them, grew up with technology and view it as an integral part of life, having been referred to as "digital natives." Baby boomers and older are considered "digital immigrants" as they were introduced to technology later on in life and 'migrated' (or not) into the digital land as a young adult or later. It is important to realize that not all digital immigrants and not all digital natives are created equal. While most digital natives are tech savvy by the default of their being born into and around technology, others do not have a knack for technology and computers, nor an inclination. Similarly, Digital Immigrants fall into three major groups: "Avoiders," "Reluctant Adopters" and "Enthusiastic Adopters." (For more information on the digital divide see the article by the co-authors of this article, Digital Native Azzia Walker and her Digital Immigrant father, Ofer Zur at Zur and Zur, 2010).
Applying these categories to psychotherapists and counselors generally means that the majority of them fall into the "Digital Immigrants" group. From my extensive experience in dealing with psychotherapists in my ethics and private practice seminars, most of them fall into the "Avoider" or "Reluctant Adopter" categories. Obviously, the majority of newly licensed psychotherapists are younger and, by definition, are considered "Digital Natives." Some of the tensions that therapists experience with colleagues and clients is primarily due to differences in attitudes towards modern Internet technologies and knowledge and capacities in regard to the digital landscape. The younger and the older generations generally significantly differ in their attitudes towards privacy and self-disclosure. From Facebook to YouTube many younger people expose highly personal and intimate aspects of their lives for the world to see, which makes most Digital Immigrants cringe. Young clients may not think twice about sending an e-mail or text with intimate details or posting a Friend Request to their therapist's Facebook page. It is very important that psychotherapists, especially the Reluctant Immigrant ones, do not arrive at ethical conclusions that are based on technical ignorance or basic intimidation of the latest technologies.
Following are a few additional considerations on the issue of social networking for therapists:
Psychotherapists do not need to have a social networking profile. Most digital natives understand that members of the older generation do not necessarily enjoy time online quite as much as they do. Nonetheless, it's important for digital immigrants to understand the world that many of our clients, especially young ones, live in.
Clients may be Facebook friends with your spouse, colleagues, and friends with or without the knowledge or awareness of you, your colleagues, spouse, or friends. As Zur's (2008) article on the Google Factor explains, therapists must come to terms with the inevitability of online transparency and learn what they can control (i.e. what is posted by them on your social networking profiles and their own websites) and what they cannot control (i.e. what other sites or profiles post about them).
Some psychotherapists may choose to add a statement to their Office Policies stating that they do not engage in social networking with clients. However, such a statement is not going to protect against the need for discussion with the client should the client send a request, nor will it eliminate the potential feeling of rejection by clients. See more details on this issue in the next section.
If psychotherapists choose to interact with clients on Facebook or other social networking sites, they may want to define the parameters of such involvement in the Office Policies.
Some people propose that psychotherapists have two profiles, a professional one and a personal one. This is similar to having a professional Page and a personal profile. A professional profile can be managed via privacy settings much like a Page.
Whether therapists choose to have a Facebook profile with client interaction, a page, or neither, it is important that they are informed about their options and make choices that are ethical, legally sound and are consistent with their level of comfort with digital mediums and the location and nature of their practices. There is no one way to go about this, and many therapists are learning as they go. What is important is to be conscious, be informed, learn about privacy online, take necessary precautions, and seek consultation when needed.
Informed Consent & Social Networking
While there is no clear standard of care in regard to online social networking for psychotherapists and a result, many ethicists emphasize the importance of informed consent. Here is an example of a "Social Media Policies" section, that therapist may include as part of the Informed Consent or Office Policies given to clients prior to the first session:
SOCIAL NETWORKING AND INTERNET SEARCHES: At times I may conduct a web search on clients before the beginning of therapy or during therapy. If you have concerns or questions regarding this practice, please discuss it with me. I do not accept friend requests from current or former clients on my psychotherapy related profiles on social networking sites due to the fact that these sites can compromise clients' confidentiality and privacy. For the same reason, I request that clients do not communicate with me via any interactive or social networking websites.
The 2014 ACA Code of Ethics added a requirement for counselors with an online presence to distribute a social media policy.
Digital technologies, including Google and social networking sites, present numerous professional opportunities and ethical challenges. The ethical implications of social networking with clients, like many other cutting-edge Internet issues, are neither clear nor established. Psychotherapists are invited to proceed thoughtfully and cautiously as they navigate through the uncharted digital landscape.
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Zur, O. & Zur, A. (2010): On Digital Immigrants & Digital Natives: How the digital divide creates conflict between parents and children, teachers and students, and the older and younger generations .Online Publication. Retrieved from http://www.zurinstitute.com/internetaddiction.html.
Ofer Zur, Ph.D. is Director of the Zur Institute, Inc. which offers over 170 online CE courses for psychologists. The Institute's website is www.zurinstitute.com and correspondence regarding this article may be addressed to Dr. Zur at email@example.com .
Azzia Walker, B.A. is Director of Social Media Marketing at the Zur Institute, Inc. and runs the Zur Institute's Facebook page at http://www.facebook.com/ZurInstitute and Twitter account at http://twitter.com/zurinstitute . She earned her B.A in Philosophy from U.C. Berkeley in 2009; among her interests are psychology of the web, holistic healing, somatics and Aikido. Her website is at www.azziawalker.com .Source: www.zurinstitute.com