Tuesday, January 26, 2010

Facebook, Psychotherapy, and Professional Ethics

Melinda Lewis, who teaches Social Work at the University of Kansas, raised fascinating questions about social media and social work ethics on her excellent "Classroom to Capitol" blog yesterday. I've excerpted four from her post, with my responses in italics:

1. Every social media expert advises that success requires an infusion of ‘personality’ in order to connect with one’s followers. I get this–I see that I receive much more response to tweets or Facebook updates, for example, that include some personal tidbit–but it makes me wonder, when does this raise the risk of dual relationships? How much disclosure is too much disclosure? How do we engage with our targets without blurring those boundaries in potentially harmful ways? Should you ever ‘friend’ a client? Now that the opportunity exists, is it harmful to the professional relationship to decline?

By "dual relationships" Melinda presumably means situations in which a social worker or other mental health clinician betrays professional responsibilities by carrying out other agendas with the patient. (The extreme form of this in my own profession occurs when psychiatrists have entered into sexual relationships with their patients.) In principle it's easy to assess the ethical appropriateness of "disclosure" - does it serve the interests of the patient, and is it consistent with the norms of the profession? In practice it can be tough to figure out. Being too stiff and formal tends to undermine clinical trust and effectiveness. But "inappropriate" disclosure can distract from the goals of the treatment and, potentially, lead down a path to various forms of harm.

The best way to "engage...without blurring boundaries" is to be aware of the question and to consult with colleagues at moments of uncertainty. The problem I see with "friending" a client is that Facebook, unlike email, isn't 1:1. I felt entirely comfortable using email with my patients. But Facebook, by design, is a networked process. One isn't just communicating to one's patients or being communicated to in one's clinical role. I'm not in practice any more, but my current sense is that I'd be using email more and more with patients, but not Facebook.

A patient who proposes "friending" to a clinician might be hurt by a decline, or, at the other extreme, relieved. What would be harmful to the professional relationship would be not reflecting on what was wished for in the request and how the decline was interpreted.

2. What about confidentiality? While any ethical social worker would refrain from including personal details about clients in social media interactions, is it ethical to, for example, include some of the outline of a client interaction on a personal blog? Assuming that all identifying information is changed, does that make it okay? What about if the blog receives ad revenue that goes directly to the social worker?

I found the following a useful rule of thumb: if I drew on material from a particular patient, it should be disguised well enough so the patient's next door neighbor would not recognize who I was talking about, and if the patient read what I wrote he or she should feel respected. Advertising revenue is not different in principle from honoraria for talks or royalties for books, but advertising has the risk that the patient might not want to be associated with the advertiser.

3. Should social workers be allowed to blog or post or tweet about their organizational life, including frustrations with their practice setting? You see employees do this all the time, from “TGIF” Facebook updates on a Friday afternoon to generic “so sick of my boss” comments on different sites, but, given social workers’ obligation to our employers, are we forbidden from engaging in this kind of catharsis?

Writing about organizational life is fine if it's thoughtful reflection about professional issues. But we shouldn't kvetch about work conditions - that could undermine the confidence other patients have in the organization. If we're critical of our work sites our responsibility is to advocate for change, fix things, or, if it's not tolerable, get out.

4. Given the viral and unpredictable nature of social media use, how can we really ever receive informed consent from our clients for their participation? For example, a client gives permission for a photo to be posted on the agency’s blog, but then the blog gets tracked back by several other blogs, and someone tweets the post…and this is exactly what your organization wants, in terms of the response from the community, but now many more people have seen it, and in different contexts, and probably with adding their own commentary…and that’s not what you told the client when you asked permission.

These complexities mean that we should envision these possibilities with our patients - a series of "what if" questions. Years ago my practice group had a policy against using unsecured email with our patients. I didn't follow the policy. But when patients wanted to use email I made sure they understood that email could be hacked, and that my group advised against using it. If they understood the limitations of email security, and if I thought email advanced our clinical objectives, I went ahead and used it. But Melinda is right that the risks are harder to anticipate with social media.


eric said...

How far will the societal pendulum swing? Self-disclosure is the norm in non-fiction literature, TV, periodicals. Does it come from a belief that objectivity is impossible and that we must therefor see subjectivity through to wherever it takes us? That to give impact to a report, the author must tell everyone his reaction to it, and the personal sources of his reaction? Frankly, it has reached saturation point for me. We are surrounded by boring blather.
In the clinical relationship, self-disclosure is still a dilemma for me, and I find remarkably little guidance. There are so many pros and cons. Even without the internet, word of mouth can spread revelations and rumors like wildfire.

Jim Sabin said...

Hi Eric

Thanks for the comment - It's always good to hear from you!

The marketing literature is full of statements about how the population yearns for "authenticity." And the media has sold its wares through human interest stories for centuries. We evolved as a social species, and we seem to be full of curiosity about what's going on inside of our neighbors' homes and psyches.

The question of how to calibrate self-disclosure in clinical care is fascinating. There's a good bit of discussion in the psychotherapy literature that boils down to - "too little self disclosure is bad, and so is too much." In the past, when I looked for articles to use with primary care residents I didn't find much.

In my own clinical work I always assumed that anything I said could become public - so I considered (1) would this piece of self-disclosure be useful with this particular patient and (2) would I be comfortable for it to be published on the front page of the local paper!



Ofer Zur said...

Therapists online transparency or self-disclosure is very complex matter in our modern digital world where clients can easily find a lot of information about their therapists. My "Google Factor" article at http://www.zurinstitute.com/onlinedisclosure.html describes the different ways that clients may find info about their therapists.
In regard to Facebook request from clients: As my article at http://www.zurinstitute.com/facebook_clinicalupdate.html explains it does not always constitute dual relationships.
Ofer Zur, Ph.D.
Director, Zur Institute

Jim Sabin said...

Hello Dr. Zur -

I'm sorry for my delay in posting your comment and responding. I was on vacation when it arrived and have been slow in catching up.

I went to your website - it's terrific! The writings you've cited in your note are illuminating - well thought out and practical. I'm sure that practicing clinicians find the site and your work highly useful.

The kind of nuanced guidance you give is important. Properly used, our new web capacities and social networking can be a useful support for therapeutic aims. Poorly used, they'll be a source of problems.

I've said to friends that if I were starting a mental health career now I'd make the interface between practice and new technologies a focus of interest. It looks as if you're doing just that. Lucky you!



Nan Franks said...

I believe if you understand the critical elements of your role and relationship, decisions about any boundary issue ( including social networking) should be not easy, but simple.

e.g. my role and relationship as a case manager is different than that of a therapist.

Jim Sabin said...

Hi Nan -

I agree that "if you understand the critical elements of your role and relationship," how to handle boundary issues becomes much clearer. I've not been in the case manager role, but with patients with significant ailments, being "therapist" involves doing a lot of what a "case manager" does. In my experience, this involved being more interactive, more disclosing, and being more of an advisor. I'd be interested in knowing more about what your experience and observations have been.