Risk Management: Social Media

Should I “friend” my clients on social media?

Friending clients is a risky business. It can lead to blurred boundaries (e.g., misperceptions about whether the relationship is personal versus professional), and can compromise client confidentiality. It may also allow the client to identify your other clients. In general, friending is not a recommended practice.

Should I have a social media presence?

Social media has come to play a central role in marketing worldwide, and professional services are no exception. It has significant benefits: it allows a flexible platform for different kinds of communications (i.e., text, sound, video, images), a way to link visitors to relevant information and resources, a wider reach for advertising, and can be accessible from many different devices. That said, whether practitioners develop a social media presence is largely a business decision.

The ethical concerns and potential risks of using social media come primarily in two forms. The first is the jurisdictional issue. Professionals should clarify on their social media sites the jurisdiction in which they are licensed to practice, so they are not viewed as intending to practice outside the scope of their licenses.

The second has to do with the level of interaction the professional allows on a social media site. For example, allowing others to post pictures on one’s wall, engaging in social media-based interactions with clients and others (e.g., blogging, allowing comments, responding publicly to questions or responses, or instant messaging), and friending, as noted above, carry risks to clients and clinicians. Among other things, client confidentiality and the structure of the treatment relationship can be compromised. There is also the potential problem of how long it takes to respond. If not structured well, clients may assume that instant messages or other postings will come to the immediate attention of and be quickly responded to by the professional.

Using social media privacy settings that limit levels of interaction (such as comments or postings), can help mitigate the ethical and legal risks of using social media with clients. So can providing an office or organizational policy (or informed consent) explaining whether, to what degree, and how the professional will interact and use social media with clients. An example of such a policy can be found here.

Are clients Googling me? What does it matter?

Yes, clients are most likely Googling you. Most clients use search engines to find information about health care in general (up to 80% according to the Pew Foundation; Fox, 2006; 2013), and health care providers in particular (some 69% found personal information about their psychotherapists in one sample; Kolmes & Taube, 2016). Professional information that clients find online can be quite useful. It can orient potential clients to the kinds of services professionals provide, and where and when those services are available, and it can inform and link potential clients to resources in regards to the concerns, symptoms, and interests they may have.

The finding of personal information can, of course, range from innocuous (e.g., provider education and age) to more invasive. Clients not only can find current home addresses and names and ages of provider family members, but also the clinician’s religious and political affiliations, likes and dislikes, hobbies, dating/relationship status, and even the activities of children, partners, close relatives, and friends. Clients who find such information about their providers may react to differences or similarities in a myriad of ways — and at least one study suggests that most clients do not disclose these searches to their providers (Kolmes & Taube, 2016). Thus, client searching matters in that it may affect client levels of trust, shame, and willingness to disclose, distress, or worry about their activities in relation to the provider, yet such effects may be out of reach for the provider to know, understand, and include in the treatment. For some providers, unintentional disclosure of personal information to clients can lead to a sense of vulnerability, intrusion, and distress at having little control over what is known about them.

Increasing numbers of providers have shifted their approach to this problem by coming to expect that clients will seek and have personal information about them. This expectation allows the provider to routinely invite clients to discuss what they know, the impact of that knowledge, and provide the opportunity to address client concerns, distress and anxiety.

Other strategies include professionals refraining from posting personal information online (e.g., pictures of family gatherings on a Facebook wall), using privacy settings on all online accounts (such as on social media, as noted above), requesting that inaccurate or misleading information be removed from offending sites (though see the section below on online review sites), and monitoring what others publish about them online. The latter approach can take two forms: using search engines to routinely search online for one’s personal information, and setting up alerts (e.g., Google alerts: see this to learn how to set these up). Note that such alerts do not determine whether someone is searching for a professional’s personal information; they just notify us when something has been published about us on the Internet.

Notwithstanding such efforts, it has become increasingly difficult to maintain personal privacy in the digital era. Being prepared to invite clients to talk about what they found online and engaging in thoughtful clinical interactions will be necessary, even for professionals whose use of the Internet is very limited.

Should I Google my clients?

Our view is that Googling clients without informed consent and a clear clinical purpose is at best unwise, and at worst potentially unethical. The problems with Googling clients without their knowledge and agreement include the potential for violating privacy expectations, undermining client autonomy, undercutting trust and the client’s timing and sense of safety, and creating boundary dilemmas (Kaslow, Patterson, & Gottlieb, 2011). It also risks potential conflicts for professionals who find online information about clients that contradicts the client’s self-presentation in ways that make it difficult to empathize or align with the client. Further, there is the problem of whether (and how) to document such searches (given that clients have a right to access their records). If clients are informed and understand the purposes of such searches (e.g., in a forensic evaluation), the aforementioned risks are diminished considerably. Note, also, that accessing simple contact information, or searching for information about a client when there is an emergency, are reasonable exceptions to this usual approach.

How can I maintain a professional presence online?

Having a respectful and informative professional online presence is becoming an increasingly important marketing tool for healthcare providers. There are a variety of platforms, including, for example, social media (see above), referral sites, and professional website hosting offered by commercial enterprises. A quick search online will reveal dozens of options, including services to assist professionals in the development of their sites. Most professional websites provide a main page where descriptions of the provider, his or her approach, the nature of services that are offered, images or videos, and contact information can be accessed. The ability to host and create blogs, provide informational resources, and link one’s page to Google places, LinkedIn, and other Internet-based services is also common on these sites. Of course, the usual ethical and risk concerns in advertising that exist in more traditional hard-copy forms apply to these sites. For example, maintaining accurate and honest information on the site, refraining from confusing or misleading the public, avoiding the solicitation of testimonials of current clients or those who might be vulnerable to undue influence, and related standards, all apply (APA Ethical Principles, 2010, 2016, Standard 5).

However, these sites pose a number of additional ethical and risk challenges. Among other things, there are issues of privacy and the tracking of those who visit one’s site. Most sites allow providers to determine where the person who visited has been online, so as to determine which links provide the most responses. (this function helps in deciding where to place one’s efforts and resources in advertising). Many people are not aware of such tracking, however, and there is some debate about the degree to which providers should be using this function and, if they do, whether they should inform potential clients.

Another privacy issue is that almost all professional online sites give a method for directly contacting the provider via a “contact me” option. This option usually includes identifying information about the prospective client, and allows for some amount of disclosure on their part. Unless the site hosting the provider provides adequate assurances of the privacy of such communications, these methods are not likely to meet professional confidentiality standards; they are more akin to using standard emails on the open Internet. As a result, providers should either forewarn site visitors that such contact methods are not secure, or provide a method of secure emailing. Another important caveat should always be added to such “contact me” emails; that is, that contacting a professional does not mean that a professional relationship has been created. Of course, using a telephone number continues to be a relatively private, albeit less seamless, technology to use.

In addition, the degree of interactivity of online sites poses ethical and liability risks. Mere provision of information — or what Recupero and Rainey (2006) called a “passive” website — is unlikely to raise more than the usual issues regarding advertising. But when professionals use what is termed “active” material on their sites, complexities can arise. Active sites, according to Recupero, involve interactions that could lead a client to the not unreasonable assumption that a professional relationship has been formed. For example, when practitioners provide depression screening measures on their websites, and encourage visitors to take and review the scores of such instruments: or when interventions are offered following the completion of the depression screening instrument, it leads to a potentially problematic implication. Even putting aside validity and reliability concerns, site visitors who interact with these resources may be led to the conclusion that they have assessed and begun treatment — without ever having so much as met the practitioner. Professionals must therefore be clear about the nature of the relationship (or the lack thereof) that is established by visiting and participating in any activities on a professional online site.

References:

Ethical Principles of Psychologists and Code of Conduct. (2002, with 2010 & 2016 Amendments). In American Psychological Association. Retrieved from http://www.apa.org/ethics/code/index.aspx

Instructions to create Google alerts retrieved from: https://support.google.com/websearch/answer/4815696?hl=en

Kaslow, F. W., Patterson, T., & Gottlieb, M. (2011). Ethical dilemmas in psychologists accessing internet data: Is it justified? Professional Psychology: Research and Practice, 42(2), 105-112. DOI: 10.1037/a0022002

Kolmes, K. & Taube. D.O. (April 2016) Client discovery of psychotherapist personal information online. Professional Psychology: Research and Practice, Vol 47(2), 147-154.

Online Health Search. (2006). In Pew Research Center. Retrieved from http://www.pewinternet.org/2006/10/29/online-health-search-2006/

Health Online. (2013). In Pew Research Center. Retrieved from http://www.pewinternet.org/files/old-media/Files/Reports/PIP_HealthOnline.pdf

Recupero PR, Rainey SE. (September 2016) Characteristics of e-therapy web sites. Journal of Clinical Psychiatry, Vol. 67(9):1435-40.

Social media policy retrieved from: https://www.trustinsurance.com/resources/articles/sample-electronic-communication-policy?ID=34&tabid=168.