Consider this Before “Friending” a Client
The same questions counsellors use to make wise decisions about dual or multiple relationships in the real world may be employed when considering the ethical consequences of engaging in an online dual relationship with a client:
- Is entering into a relationship in addition to the professional one necessary, or should I avoid it?
- Can the dual relationship potentially cause harm to the client?
- If harm seems unlikely, would the additional relationship prove beneficial?
- Is there a risk that the dual relationship could disrupt the therapeutic relationship?
- Can I evaluate this matter objectively? (Corey et al, 2011, p 273).
Specific to the question of social media, Zur (2014) recommends a comprehensive review of the situation through a set of questions that many digital immigrants (internet users old enough to compare the contemporary world of digital technologies with the “ancient” world before connectivity) would need to get consultation in order to answer accurately. They involve examination of all factors, from the profile contents and set-up through who gets access in what therapeutic context to the meaning of the request for both client and counsellor.
What is on the Facebook profile?
A strictly professional profile should be considered in a different light than a personal one, which may include family photos, photos from a party, holiday video footage, and so on.
Does the therapist have a Facebook Page or only a Facebook Profile?
Having a Facebook Page can reduce many problems in regard to self-disclosure, confidentiality, privacy, and other areas, although as we noted it may not entirely eliminate the problems. In many cases, the mental health professional is not just a counsellor, but also an author, presenter, workshop facilitator, group leader, or centre manager. A Page can cover all those areas of professional activity and also note details about the clinical practice. Unlike a Profile, a Page is for professional interactions and generally respected as such. The American Counseling Association Code of Ethics (revised in 2014) requires that counsellors keep professional and personal Pages separate (American Counseling Association, 2014). The Facebook Page works quite well to meet this requirement.
Does the therapist use privacy controls to control access?
Many digital immigrants may not realise it, but mental health professionals using social networking sites can segment the list of “friends” into different groups, such as Public, Friends, and Close Friends. Using the segments, professionals can post things that belong only to one group and control the postings that each group can view. Thus, when one adds a client to a list, accepting a friend request from that same client theoretically does not have to mean the client gets unfettered access to the clinician’s or clinic’s profile. As Kolmes (2010b) and Younggren (2010) have pointed out, however, privacy settings do not always provide the privacy they promise to protect.
What can a client view on the therapist’s profile?
Obviously it is imperative to understand what clients may be privy to on one’s social networking site. The prerequisite understanding, then, is how privacy controls work and how to add “friends” to lists such as, say, “Public” or “Friend” before one considers accepting a friend request from a client. Counsellors can decide what friends on various lists can see. It goes without saying that privacy controls are extremely important when therapists have sensitive information on their profile. The controls are also useful in helping professionals determine how clients and others can communicate with them on their site: can they write on the wall? Send a message? For digital immigrants and/or anyone unsure of what a client will be able to see once they are added to a particular list, the Zur Institute (2014) recommends using Facebook’s privacy test. One types in the name of the client and can then see what the profile looks like from that person’s point of view.
What is the context of therapy?
To adequately consider this question in the context of a “friend” request, we are in the business of acknowledging counselling and psychotherapy as art, not science. A full set of factors determines whether accepting a request is inappropriate or not, clinically beneficial or not, and ultimately, ethical or not. The context of therapy includes client factors, such as the person’s diagnosis, age, culture, and relationship to technology. It includes consideration of the setting of the therapy, such as whether it takes place in a private practice, a clinic, a hospital, or a prison, and what the therapeutic relationship has been like: one of trust? Distance? Warmth? Or is there a marked power differential? Different modalities of therapy call for different approaches, and experienced therapists know that the therapy of a client being treated with Cognitive Behavioural Therapy is likely to be very different than that of an existential approach, both of which are different again from psychodynamic or transpersonal modalities. Finally, we cannot fairly exclude the therapist from examination here, and must ask: what are the counsellor factors that make a difference? These might include training, age, relationship to technology, and comfort with self-disclosure.
Who is the client?
If it is your high-functioning colleague or possibly a long-term client who belongs to the “worried well” category, the situation is clearly different than if the client is a very disturbed person with intense needs, who may need clear limits, whereas the former categories may benefit from a flexible approach.
Why did the client post the request?
This question may hit at the heart of the issue better than most others as we seek to understand harmful secondary relationships. The digital natives — all younger clients — have very different attitudes toward disclosure via social media than do some digital immigrants, especially the sub-group of the latter referred to as “reluctant adopters” (the category into which many older mental health professionals fall) (Zur & Zur, 2010). The natives share much with many and typically send out “Friend” requests to just about everyone they know — it’s a routine thing! — and often to people they don’t know personally. This question blends into the next one.
What is the meaning of the “Friend” request?
Was the request to become friends just a routine thing by your digital native client, as in the question above? Or alternatively, are you dealing with a client who habitually attempts to push boundaries and has little sense of how intrusive he or she is? By making your therapeutic relationship public, might the client be attempting to de-pathologise the therapeutic work? Is the client seeking a deeper relationship with you as therapist than what might be appropriate?
What is the nature of the therapeutic relationship?
Overlapping with previous questions, we must ask here how the relationship is constellated. Is it family or group therapy? Intensive, individual psychodynamic therapy? Or perhaps it is someone who comes only intermittently for follow up: say, once or twice a year over a long period of time? Clearly, different types of therapeutic relationships need different communication approaches.
Where is the therapy taking place?
As per the comments on the context of therapy, above, we must ask how the setting for the therapy — that is, private office, clinic, home office, community mental health centre, hospital, or prison, etc. — has a bearing on the request to “friend”. A request from a highly paranoid new client in an inpatient mental health setting needs to be seen differently than a colleague who comes for intermittent long-term therapy.
What is the community location of the therapy?
In a small or isolated rural community, everyone seems to know everyone else’s business anyway; possibly no privacy settings will suffice! A more anonymous, urban, metropolitan environment may be easier in this regard.
What does saying ‘yes’ to the friend request mean for the mental health professional?
Let’s say you are the professional who receives the request. The client will undoubtedly have developed or be developing transference to you; what sort of transference is it when you decode it? And just as importantly, what is your countertransference to the client? Your feelings, desires, and aspirations must be explored, not only with respect to the client, but also with respect to the friend request and to technology.
What is the effect on other or potential clients?
Current, past, or potential clients may become your online “friends” — or your clients’ friends. People often make the acquaintance of others online, including through the profiles of other friends. The degree to which your clients are allowed to interact on your site will affect how likely they are to get to know your other friends. The default option on most sites is to make one’s friend list public; if you do that, you must consider the aggregate effect on your connections.
What are the ramifications of accepting a friend request from a client for confidentiality, privacy, HIPAA compliance, and record keeping?
This is one of the most important considerations in deciding to accept the request or not.
Does accepting a friend request automatically constitute a dual or multiple relationship?
It may or may not. If the friend acceptance is likely to create a dual relationship, you as the treating professional must assess whether the dual relationship is ethical or clinically advised.
How might the therapist’s response to a friend request affect treatment and the therapeutic relationship?
As with most types of boundary crossings and dual relationships, counsellors must do a risk/benefits analysis. If it is you faced with accepting the request or not, your task is to think through whether accepting is likely to cause harm, exploitation, loss of objectivity, or loss of therapeutic effectiveness. The 2014 ACA code of ethics has added in a section stating a new requirement that counsellors avoid “personal virtual relationships” with clients. What does that mean? Zur (2014) contends that, while it is unclear, it would likely include creating friend relationships with clients on the therapist’s personal social media profiles (section adapted from Zur, 2014).
- American Counseling Association. (2014). 2014 ACA Code of Ethics, as approved by the ACA governing council. American Counseling Association. Retrieved from: hyperlink.
- Corey, G., Corey, M.S., & Callanan, P. (2011). Issues and ethics in the helping professions (8th Ed.) Belmont, CA: Brooks & Cole.
- Kolmes, K. (2010b). A psychotherapist’s guide to Facebook and Twitter: Why clinicians should give a tweet! Retrieved from: hyperlink.
- Younggren, J.N. (2010). To tweet or not to tweet, that is the question. The Clinical Psychologist, Vol 63, no 2, pp 18-19.
- 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. Zur Institute. Online publication, retrieved from: hyperlink.
- Zur Institute. (2014). To accept or not to accept? How to respond when clients send “Friend Request” to their psychotherapists or counselors on social networking sites. Retrieved from: hyperlink.