Back in April, I received this short email that ended up resulting in a rather lengthy email exchange. Over time, it has become obvious that this is a conversation that some of you might also be interested in reading and / or contributing to.
I asked the author for permission to share a large part of our correspondence and she agreed. Based on the nature of this discussion, all identifying information has been changed or omitted. I’ve added headings to help you follow our exchanges more easily.
This is the first of a two-part post.
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The Twitter and Boundaries Question
Hi Tamara,
I’m a newly-graduated counsellor (in Canada) with a Twitter account. I have just been followed by a former client who had asked me out (among other things that demonstrates I want to be really vigilant about relationship clarity).
What are your thoughts about professional boundaries and Twitter? I want to get thoughts from a colleague who is not prima facie techno-phobic and therefore would right away say, “No Twitter!” so I thought I would ask you.
Looking forward to receiving your reply.”
Tamara’s Disclaimer . . . 
I am not familiar with Canadian or local laws and, I want to remind you, that I am not an attorney. 🙂 Having said that, you need to be really clear what the legal implications are concerning this former client so please consult locally with an attorney and also mental health colleagues to to make sure that you are protecting yourself legally and ethically.
I tend to be rather rigid about my boundaries with clients and social media. That means I don’t knowingly follow, friend, or connect with clients as a rule. And, I discourage them from following, friending, or connecting with me via social media, too. In fact, I try to restrict my electronic interactions with them to scheduling and logistical concerns only.
Best Practices
Regardless of the social media tool you use, best practices would indicate that you separate your business accounts from your personal accounts and set up appropriate privacy settings so that clients only have access to your professional information. If you haven’t done that already with your Twitter account, do that NOW.
Best practices also suggest that you develop and use a Social Media Policy for your practice. (I recommend taking a look at Dr. Keeley Kolmes website to guide you.) Twitter can be an excellent way to drive traffic back to your blog and introduce a wider number of people to your services but it is a little bit like the Wild Wild West in that those boundaries are just now being considered and put in place.
A Mental Health Professional’s Responsibilities
My understanding is that in whatever ways you find out information about your client – via a phone call, an anonymous “tip,” by searching online, by reading their blog or comment on your own, or by them sending tweets or other messages electronically – as her therapist, you are then legally and ethically responsible for what you do with that information. (This just came up in my consultation group when a therapist discussed that she had read her client’s blog posts referencing her own self-harming behaviors.)
However, Twitter is a good example of a therapist not having any control over a client’s choice to follow you. If I know that a client is following me, then this warrants a conversation (or two or three or. . . however many it takes) with the client. In that conversation, we are discussing the clinical implications of that client following me – benefits and challenges both.
Transference and Counter-transference
The invitation to meet outside of your professional relationship is just one more reason to set up really clear boundaries with all of your clients – and boundaries that you can stick to.
If you find yourself flattered, seriously considering this date with your former client, or find that you have other (positive or negative) strong feelings related to this invitation, you should consult with other seasoned therapists in your community to gain some clarity about how you might have knowingly / unknowingly contributed to the unfolding events. (We ALL – knowingly / unknowingly contribute to boundary issues with our clients on occasion. The trick is learning how to recognize those contributions and figuring out how to clean them up!)
Informed Consent
Assuming you had a written policy concerning these matters at the time you saw this client – and a policy forbidding this type of behavior, I would rely on this to guide you. And, of course, if you did not discuss the appropriateness / inappropriateness of dating your therapist, then you might want to go back and strengthen that part of your informed consent process.
And, as for your response to your client, I would recommend a BRIEF phone call to say this is not acceptable to you and ask them to unfollow you immediately. Having said that, of course, your former client may or may not choose to comply. You always have the opportunity to block a follower on Twitter and that’s exactly what I would do.
Document, Document, Document!
I would also suggest that you document this entire series of transactions with your client in your client’s clinical record. It is likely that this client may try to reconnect with you in other ways and that boundaries are an issue for this client. Your documentation in the clinical record may protect you down the road.
I hope some of this helps you decide how you are going to handle your client!
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On Thursday I’ll be posting the second part of this post.
Hi Tamara,
Very interesting. I’ve pondered this myself, and I came to the opposite conclusion. Although I must say up front that I only participate on Twitter as my professional self. So, my tweets are always directly about my work as a psychotherapist. I specialize in working with survivors of rape and other sexual assaults, so my tweets are pretty much limited to 1) links to my own blog on that topic, 2) retweets related to sexual assault or abuse, or 3) tweets or retweets about counseling or mental health in general. I’m mindful that my clients and former clients are likely to read my tweets. And I wouldn’t necessarily know it. Unlike with Facebook, people can read your tweets without actually following you. I’m pretty comfortable with that, just as I’m comfortable with my clients scouring my web site for kernels of information about me, or googling me. I just try to make sure that I’m aware of the information that they may find that way.
But maybe I’m being naive? Assuming that I’m keeping my tweets professional, what exactly would be the harm in “letting” my clients read them? Or are we mostly concerned about them reading more personal tweets here?
Peg
Hi, Peg! I’m not sure that you and I are drawing opposite conclusions unless you are saying that you do not believe it is necessary to have a Social Media Policy or to discuss the use of social media and its impact on your clinical work with your client. Is that what you are saying?
You and I are definitely on the same page as far as needing to keep professional and personal accounts separate. Those boundaries though are sometimes easier said than done depending on your clinical orientation of course. The sticky situations might include
+ The therapist in recovery who is tweeting about 12-Step Meetings in her own community and her new client then learns about and attends the therapist’s own 12-Step Meeting
+ The therapist who tweets compassionately about her work with pedophiles and also happens to work with survivors of sexual abuse
+ The pastoral counselor who tweets about needs i.e money, clothing, food in his own congregation (that includes his clients’ needs)
+ The hypnotherapist who is announcing the start of new hypnotherapy classes (and then has a current client want to sign up for them,too)
You absolutely cannot control who sees your tweets unless you choose to block someone from seeing them. Even then I’m not sure if someone else retweets your tweet they might be able to see those retweets. So, of course, with the best intentions and the best boundaries in the world . . . clients will see them if you are on Twitter. the bigger question is . . . What do you plan do to about them and are you being proactive?
Oh, no. I absolutely believe in having a social media policy, and I go over mine with new clients, and any time I have any interaction with a client around social media! So, I guess we do agree, then. Where I think we have different conclusions is around blocking clients on Twitter. I suppose it might make sense to block a client who has officially followed me, but it’s not my policy to do that. I just make sure that I don’t tweet anything I wouldn’t want a client to see.
And it’s good to be reminded often that things can get really complicated in the world of social medial. As they do in every aspect of this work. Situations will inevitably arise that we have not anticipated. I appreciate all of the work you do to give us a place to talk it all through, either before or after!
– Peg
🙂 And, I appreciate, Peg, that you help to create this safe place to talk it all through, too!
Hi Tamara,
The issues around ethics, implications and social media usage for MH professionals is one that still strikes me as being “under construction” in the larger community. Building upon Peg Shippert’s sentiments, is it naive to think that as long as a counselor is cognizant and prepared to address any issues that may come up with clients, that there’s no harm in maintaining a professional but active presence in social media? How do you address this and the links between this blog site and your clinical practice site? Do you ever worry about clients accessing (or joining!) this site and attempting to interact or use the information in a harmful way? So many questions! Thank you for bringing up this important topic.
Hi, Deanna! Thank you so much for thinking about these issues and probing the minds in this community in such a conscientious way. That’s exactly what I hope for in our community here at Private Practice from the Inside Out.
You are absolutely right that the ethics, the professional standards, and even the laws are still “under construction” and continuing to change. That’s true concerning social media; but that’s also true in many (if not most) other areas related to our work as mental health professionals.
Likewise, to assume that if a therapists is “cognizant and prepared” that there is then no potential for harm in engaging in social media for professional purposes is indeed naive! There is potential for harm at every step in the work that we do. And, lest you think I am making light of your concerns, I am not! There are many ways that therapists can do harm or increase harm via social media. I just want to underscore that that is true in many other areas of our work as well. And, as therapists, we, too, are more vulnerable in these venues than in some other more traditional venues.
Deanna, your questions are so important that, if you don’t mind, I would like to take them into an actual blog post to make sure that others get the benefit of the information I can provide. I hope you are ok with that. Stay tuned! I’ll try to get them up later this month! And, thank you again for taking time to read and ask such thoughtful and relevant questions!
Your statement, “There is potential for harm at every step in the work that we do,” serves as a poignant reminder of the importance in remaining up-to-date with the practice (not just new ways of working with clients but updates in ethical and legal considerations!)
It really makes one stop and think (and talk to colleagues/ seek consultation) before coming to a decision and taking action. Of course most of us do this when dealing directly with clients but it’s an excellent sentiment to apply when considering delving into the social media world or online therapy. Thank you for that!
I look forward to your future blog post!
Thanks, Deanna. You hit the nail on the head. I understand why I and others have lots of questions and concerns about an online presence. It’s new territory and we should be cautious. But, the research I’ve seen over the years indicates that it’s the old stuff that we get sloppiest with rather than the new territory. Yes, I’m sure there are exceptions to that but for most of us . . . over time . . . it’s too easy to get careless with the stuff we’ve “done forever.”
I’m looking forward to addressing the new stuff, for sure! But, let’s not get confused and think that we can’t learn how to do it . . . and do it well . . . with respect for ourselves and our clients, too.
Hi Tamara,
Great post! Another resource here- Dr. Keeley Kolmes co-authored our Ethical Framework for the use of Social Media by Mental Health Professionals: http://onlinetherapyinstitute.com/ethical-framework-for-the-use-of-social-media-by-mental-health-professionals/ and folks are free to see how I incorporate social media into my informed consent: http://www.mentalhealthonthewebblog.com/informed-consent/
Hope this is helpful!
DeeAnna
DeeAnna! Thank you for taking time to share such great resources! I so appreciate your generosity in sharing what you know.
Hey! I just took a quick peek at your links . . . . Your website looks different . . . and beautiful! Has your site had a facelift or was I remembering a different website? Either way, love the banner and the uncluttered look of it!
Thanks for providing these helpful links! Incorporating the social media topic in informed consent was something I was wondering about and your example completely answered my questions. Thank you!
Deanna, so glad I could help!
It is a new look! We are thrilled! Our primary goal is to make the information at Online Therapy Institute/Online Coach Institute much more accessible! Thank you for the kind words!
It looks beautiful!
And, gang, if you are looking for info about online therapy, go check out DeeAnna’s website. It is a treasure trove of resources that I can’t get along without!
For those of you on LinkedIn who happen to belong to the Child and Family Group, you may want to check out the commment just left here related to this post.
I believe you can block users on twitter if you don’t want them to follow you, however Pinterest has no way of controlling who follows your posts at this time, just thought i’d throw that out there.
Thanks, Jill! That’s exactly right.
Hi Tamara,
What are your feelings about a client who requests to be a contact on your professional “LinkedIn” page? Or is that another blog entry topic altogether?
Hi, Aaron – That’s a great question and I can answer it right here. I decline those requests to connect with clients on LinkedIn and then have the conversation(s) with those clients that are necessary for them to understand why i.e. blurred boundaries, conflicts of interest, dual relationships, etc.
Over the years, “once a client always a client” has worked really well for me. I understand that this is not a policy that fits for everyone but it is not uncommon for me to terminate with a client and have them resurface to do some more work 5+ years after we thought we were “finished.” That’s only possible because I haven’t blurred the boundaries during their absence. And, truthfully, it’s my own private “pat on the back” that our relationship was solid enough and our work together was valuable enough that they felt they could return. That means a lot to me. It’s a smart business decision, of course. But, it’s also confirmation that I am / was on the right track. I value those a lot more than one more connection on LinkedIn on Google+, friend on Facebook, or follower on Twitter.
What about you, Aaron? How do you feel about clients who request to connect with you on Social Media?
Honestly, its not really an issue I deal with much. I don’t have a Facebook Page or a Twitter account. Only recently have a few former clients asked me to be placed in their contact list for Linked-In. I haven’t really thought about this potentially being an issue of blurred boundaries, should they want to come see me again for services.
Got it! That’s how I’ve had to figure a lot of things out, too, Aaron . . . . I didn’t anticipate those questions about boundaries and then, before I know it, they are staring me in the face! Especially in the early years of my practice. As time goes on, I think we all get a little better at (and a little more motivated to) seeing all the possible scenarios!:)
Wish I had bookmarked a LinkedIn discussion that I was a part of earlier today. Someone was expounding on the many ways they had run into problems after the fact by passively allowing a client to follow them in social media. Can’t remember how to access that discussion right now though . . . .
Enjoy the journey!
Another consideration is that anyone–including current and former clients–can easily create a false identity. So, IMHO, whatever you communicate in social media should be with the assumption that it’s your client(s) with whom you’re communicating.
James, welcome back! You’ve got that exactly right! Regardless of the platform . . . and that includes commenting on blogs . . . if you are saying it online, assume it’s in the public eye!
I was a graduate clinical social student and left the field to attend to some personal health matters of my own. However, I do maintain my interest in the profession, interactn with former classmates, professors, and do at times (depending upon situation and circumstance interact with clients) that I have worked with and here is what I will say to all of what has been shared.
1) Clients are aware that the relationship is professional at all times. Meaning, never will an intimate relationship be formed, and the ones I have dealt with are aware that what I share with them is done only in situations where it is deemed to be beneficial to them and at times I do seeek consultation before certain forms of self-disclosure. I make them aware, as they should be, that there are issues surrounding “dual relationships” how a relationship might ensue after services end, etc.
2) I also let my clients know I may if I think it’s in their beest interest and mine (which are always taken into consideration) for both legal, ethical, and professional reasons, that I may choose to not interact with them PERSONALLY as in one one one but may respond to their posts or inquiries more globally because in the world of social media you are NATURALLY going to cross paths coming up in searches, your name comes up, your profile comes up, your picture comees up and they need to know that there are professional guidelines you need to adhere to that are consistent with your profession depending upon what your credentials are.
3) I also do let some clients know that in some settings (i.e. crisis centers) which I have worked I will NOT accept a friend request. It depends upon the environment I met them in and I do let them know this so there is no confusion of abandonment or mis-interpretation as I want them to know that every decision made in the way I use social media and how it relates to my work has to take into account first and foremost —————-what is in my client’s best interest not always what’s in my best interest.
It is fine to have casual contact, friendly hellos, updates, more detailed updates from time to time and the relationship can grow because we allowed it to grow or it can be still because we simply do not feed whatever is being fed to us, etc. I say it’s a relationship we engaged in wheether for pay or not it’s still a relationship ————– treat it like all relationships ———- with good boundaries and being open, honest, and we also need to stop being so rigid in our boundaries also. Clients are more than just clients they are mom’s, dad’s, brother’s, our coaches, our teachers, and we need to see them as people and people we can learn something from also and stop putting ourselves above when truth is we’re no better or no less than. I do agre that no matter when the professional relationship has ended dating is inappropriate, going to bars is inappropriate, and anything that has the potetnial to exploit them (regardless) if current or past client. Coffee (maybe) and in limited circumstances and with it made clear if necessary (again depending on the client) taking into consideration why they were seeing me in the first place, what their ego-strengths are, do they have the capacity detach OK and things of that nature are all factors in determining how far outside the office so to speak you can go. But, if you keep it professional, sincere, honest, then what’s the harm if it becomes a problem address it and if you must cut them off then tell them. What’s all the need for clarification about. If the relationship becomes problematic then address it directly.
Hi, Christopher! Thanks so much for joining in this conversation. You’ve obviously given this a lot of thought. I think the need for clarification is that we have digital natives, digital dinosaurs, and digital immigrants with skin in the game here . . . both clients and providers falling into these categories.
You do make some very good points though and I appreciate your emphasis on personal responsibility. And, while I agree with that in principle, I think it’s important to also consider at least two more things . . . .
1. Rules, laws, codes of ethics, standards of practice and guidelines aren’t made for those who behave in the most honorable ways with the best practices. Instead, they are made for those who fail to act in less than desirable ways.
2. Likewise, it’s also important to remember that while a therapist may fully explain – even repeatedly explain – to a client what a therapist’s intentions and general practices are, that same therapist cannot know for sure what his / her client’s experience or thoughts are or how they might change over time.
These days I tend to characterize my clients as “high functioning” and often the “worried well.” Still, none of us are infallible . . . and most of us have, at times, made mistakes . . . misjudged the nature of a client’s struggles . . . . “Diagnoses,” “ego-strengths,” even “limitations” and certainly “pathologies” . . . . These hardly represent the language of health or scientific knowledge or collaborative processes. So, to adopt policies or develop practices related to the use of social media and boundaries based on an individual client’s “health” or “needs” doesn’t seem to adequately protect either the therapist or the client very well.
Tamara:
My guess is that your issue/concerns runs deeper than what can be explained on a social networking site even one such as this given the ambiguity of email/blogging as while a question is posed it tneds to more often than not create more questions and needs for clarification and in my opinion this where good clinical supervision comes in. Good supervision will be able to help you look at your individual circumstances. I hope you do not mind my observations as I’m going to give an example:
Likewise, it’s also important to remember that while a therapist may fully explain – even repeatedly explain – to a client what a therapist’s intentions and general practices are, that same therapist cannot know for sure what his / her client’s experience or thoughts are or how they might change over time.
I would highly recommend that we step outside of categories, pathologies, labels, high-functioning/low functioning; and realize that a) our clients’ are human 2) they, like our friends, colleagues, family, and even ourselves change because no one consistently maintains the same feelings towards anything over time. Our thoughts, feelings, perceptions, reality, circumstances, and such are things that should be taken into consideration.
Regardless how you look at this,, our perspectives are too broad and it’s iimpossible to find a perspective that is completely consistent across the board. Just accept the fact this is a topic like so many others that you will never have complete agreement among people how to respond.
Hey, Christopher, I think this is a really great example of the limitations of text-based communication rather than a significant lack of agreement. I think that you and I are pretty close to seeing eye to eye on much of this. Here’s where I think we agree . . . .
1. Neither you or I appear to be fond of the labeling and categories;
2. Good clinical supervision is necessary;
3. There is room in our profession and here at Private Practice from the Inside Out for many different perspectives; and
4. Indeed, it is perhaps even desirable that we do not have to always agree!
Christopher, thank you . . . for seeing the opportunity and having the courage and sense of responsibility to engage in what many may perceive as a potentially difficult conversation. If those who are trained in the disciplines of mental health are not capable and willing to have these conversations with our colleagues, then who can? I appreciate your voice here and hope you will drop back in often to chat and challenge the status quo. We can and we should be better than that.
Thank you, Dawn, for sharing the resources found here with counselors in Canada! So happy to have you guys joining the conversations!