On Tuesday, I talked with you about some of the ethical considerations and best practices when your client / former client tries to follow you on Twitter. In one of her emails to me this same therapist also brought up her sincere desire to remain as transparent as possible with her clients. That’s the juggling act, isn’t it? Maintaining appropriate boundaries and also being as transparent and authentic as possible.
Here’s the second part of that email exchange. If you missed the first part of this 2-part post, you can find it here.
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I had always thought I did not want there to be a difference between my ‘public personal’ face and my ‘public professional’ face. I used to be comfortable sharing aspects of my personal journey on Twitter, even as a professional, because it provided people info on the context in which I practice, in other words, who I am as a counsellor and what life experience and values I bring to my practice.
But when a former client who has challenges with boundaries followed me on Twitter, it became clear to me that it is up to me to model holding very clear boundaries. Also, I became concerned about my vulnerability to a person who, while attempting to meet their needs, would not likely take my needs or safety into consideration as a priority. So I became uneasy about sharing things I formerly considered neutral.”
Congruence in Social Media
I, too, think it’s important for my public face and my private face to be congruent. However, that doesn’t mean that I am free to discuss with my clients anything and everything that pops into my head. That would be what anyone’s neighbor might do. However, as a clinician, I am trained to have strategic conversations that are confidential and always focused on my client’s best interests and my client’s goals.
Within the context of social media – that is exactly what tends to happen . . . . I can talk about the Final Four basketball games, pitch my favorite political campaign, post my health concerns, exchange a recipe, talk about family, muse aloud about the weather, rant about my pet peeves,etc. – none of which is of clinical use to my client and may, in fact, insert wedges between us or, worse yet, burden my client. There is a considerable amount of research out there noting the complications that ensue from bringing too much of me into the clinical hour.
Social Media is Never Confidential
Social media is not confidential – even when it occurs under supposedly “private” and “locked down” spaces. Consider something like Facebook – every time they do a major update, they reset privacy (and other) settings back to the original settings. Or, think about a chat room or email discussion list – again you cannot assure confidentiality – where all information goes to the servers at each end and are then housed indefinitely in their computers onsite with no telling how many people have access to them.
You Can’t Be Sure Who You Are Talking To
Clients may use an alias to connect with me – that’s certainly possible. And, others who are not my clients may choose to represent themselves as my clients. Either way, these, too, pose problems online.
Our technology is changing fast but these issues have yet to be fully addressed. In the mean time, there are therapists who have chosen to push the envelope more than me and have made efforts to mitigate these problems using code words and visual identification and encryption to name a few. And, I’m not saying that I won’t follow suit. It’s just that I tend to be more cautious and have not chosen to go those routes yet.
Boundaries Serve the Professional and the Client
I’ve been in the field long enough to have encountered more than one client with very serious boundary issues. It’s only a matter of time, I think, until every mental health professional runs into those challenges. I value my privacy. And, I value my clients’ privacy. My boundaries serve to maintain that line for me and them.
Right and Wrong and Judgement Calls
I think, perhaps, more than anything else, mental health professionals 
get paid for our judgment and making difficult decisions. We don’t have to be perfect all the time – there are many ways to do the “right” thing and sometimes there is no way to do the “right” thing. And, sometimes, what is right for my client is wrong for me . . . and what’s right for me is wrong for my client.
I don’t mean to be saying that “anything goes.” That’s not right. In fact, just the opposite is true – we get paid to be prepared to make difficult choices and anticipate the consequences. The difficult part is when my needs and my client’s needs are not the same.
I think under the circumstances you are right to not contact your former client. It is most likely in your best interest to not do so.
And, of course, it might be in your former client’s best interest to have a conversation to understand why you have the boundaries that you have. (Of course, it is also entirely possible that your client would not understand even after 20 conversations.)
See what I mean? This is all about yours and your supervisor’s best judgment. As frustrating as it is, it’s all a balancing act of judgement calls.
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So now I’m wondering, has anyone else encountered clients / former clients following you on Twitter? If so, let’s chat about what happened and how you are handling it.
Very thought-provoking. It’s made me go back and mentally review my Twitter posts, mostly to positive results! So far, most of what I post is relevant for the clinician, but it’s always possible that my clients or former clients check it out regardless. I’d love to hear what you think about clients perceiving us “beyond the veil” so to speak. While people like you (Tamara) and I don’t post much about our personal lives – likes, dislikes, sports, etc., we have blogs that speak to professionals about topics that include client care, all the while maintaining client loads. What impact, if any, do you think it could have on a client to see us discussing professional private practice issues?
Great blog!
Thanks, Stephanie, for dropping in to continue the conversation.
First of all, “beyond the veil” is such a great metaphor for you to use. The very best of my professors at the University of North Texas (in Denton) used to stress in his classes that when we are really good at what we do our work is actually quite elegant. And, when that level of work occurs our clients may perceive what we do as being “almost magic.” My profs would stress that therapists should at every opportunity demystify the work that we do rather than allow our clients to believe that it was “magic” or some type of woo-woo that was more about the counselor’s great powers.
In truth, our successes in mental health are about nothing more than professionals creating the space for our clients to the their work. We are much more event planners (for which clients can cancel the evens at any time) and space holders than the magicians and healers that our clients often imagine us to be.
Removing the “veils” . . . stepping off of the pedestals . . . taking time to deconstruct those myths about who and what we are . . . empowers our clients to be who and what they choose to be. And, I believe, to ignore those erroneous perceptions our clients have is as egregious as encouraging and even intentionally planting those perceptions because they are dis-ingenuous and dis-empowering for our clients.
Having said all of that, I want my clients to know that I am a professional counselor, coach, and consultant and that I am also business woman. And, I want them to understand how I come to the decisions I make about how I run my business. That includes why I choose not to work directly with managed care and why I charge the fees I charge.
And, when I raise those fees, I want them to understand it wasn’t random or simple greed – there were well-grounded reasons. It’s important to me that they also understand how I go about sustaining my practice . . . through marketing and referrals . . . and that I am both honored and grateful that my clients trust me enough to send their loved ones and colleagues to me! I want them to understand all of that and more!
It’s especially critical to maintain good boundaries when engaging in social media. If I have an “issue” with someone, I take it offline. I don’t email about it. I don’t tweet about it. I don’t leave snide comments on blogs. I pick up the phone and have the difficult conversation. That’s because it’s so easy to be misunderstood. (And, even with that parameter . . . on occasion – as happened this week on one of the discussion lists I participate in – I am / was misunderstood.) It happens. There are certain things that I try not to address via social media. And, when I choose to make an exception (in whatever venue) it is typically an intentional and well-thought-out exception.
Stephanie, I think I may be rambling now but hope I’ve provided a little insight into how I feel about clients “seeing me” discuss being in private practice. What are your thoughts about your clients “seeing you?”
I follow Darren Hardy, editor of Success magazine’s advice, NOTHING online is private. So I don’t have a Facebook or Twitter account just Linked In, and everything there is professional. I like it this way since I have some clients (teens) that tell me they tried to find me on Facebook to friend me. I’m think about opening a Twitter account and just following my favorite authors, speakers, etc. but still not sure.
On another note, in my town there’s an annual week long festival where a lot of drinking is involved and you’re allowed to drink beer in the streets near the festival. I had a client tell me he saw one of his teachers drinking beer and smoking a cigarette and now looks at the teacher as a hypocrite because in school the teacher tells kids that drinking and smoking is not good. The client said he doesn’t see the teacher as the same anymore.
This just reminded me how as professionals, especially therapists, we are a walking billboard and what we do, on and off line, leaves an impression on people. Nobody is perfect but it’s a fact that people are always judging us by what they see and hear/read.
Yep, that’s exactly right – NOTHING online is private. And, truthfully, neither are you “off” hours when you are outside the confines of your own home. Your reputation follows you everywhere and, Liza, you are giving a great example!
I remember that when I lived in the Dallas-Fort Worth area I was very involved in my community’s events – the social ones, the charitable ones, and the political ones. I was always out and about . . . and I repeatedly ran into clients. Being seen in certain venues (Do I really want my clients seeing me in a bar?), being seen engaging in certain behaviors (Do I really want my client seeing me sing karaoke?), being seen in certain situations (Do I really want my clients seeing me arguing with my date?) . . . . All of those things and more color our clients’ perceptions and also our relationships with our clients.
I don’t mind my client knowing I was in a bar attending a fundraiser or that I sing off key or that I, too, get mad on occasion. But, are they relevant to my clients’ concerns and therapeutic goals? Not always . . . not usually. And, if any one of those facts was relevant, I would like to have a bit more control over if / when / how those are introduced into the clinical hour. You are right, Liza, we are walking billboards for our practices and what we do matters. We don’t need to be infallible superheros and there is certainly a place for transparency in our practices . . . but there is also judgement and boundaries that come into play . . . . What we need to remember is that as gray as that line is for mental health professionals, it is often even grayer for our clients.
I’m glad I read this and I am glad that this is generating discussion. My thoughts on this are muddled because I am in the process of trying to navigate personal branding on-line while not having a position as a therapist (intern) at this time. This is important because with the job market as it looks now, I may never get a spot to begin working on my hours but I do not have the luxury of just shelving myself until things change. So at this point, I must assume I am in need of creating my own market and go forth. (And so should I not engage on the off chance that in 5 years I get an intern spot?) Which complicates how “sanitary” I can be on-line…not to mention, the horse is already out of the barn given that 10 years ago I did not know where I would be at this point in my life. So while still wrestling with this issue, I recognize that there is precious little I can do about what is already “out there”…it is complex to be sure.
I wanted to say that I think how we conceptualize what clients see us do (be it having a beer or getting our hair colored etc) may have a lot to do with our theoretical orientation. This does not mean that clients will all be accepting of what they see of course but we can’t control that can we? I am reminded of a therapist I had when I was a teenager. I was dealing with some very messy chaotic stuff and she was just so — sterile. She wasn’t cold, but I just remember the space (her included) and it was as if she wasn’t a real person or that her life was serene and uncomplicated. (I was likely completely wrong BTW.) But I do remember looking at her during one session where I had been sobbing and was very raw and thinking “There is NO way this woman has ANY idea what I’m going through.” So I don’t know. Take that for what it is worth. But it sticks with me.
As for social media and befriending/following, I believe I would add a policy to my intake paperwork (especially with teens/young adults who tend to rely on social media) that was very clear what I would and would not allow. I know there are therapists who use texting for communicating with younger clients but I hold that as a different issue than this. Anyway, it just seems to me that if the expectations are clear from the beginning, it makes it less awkward if there is an issue later.
As another example, my current therapist is on twitter as am I. As his client I have not asked to be connected, nor will I. Perhaps after I’ve moved from here and have “graduated” to a professional in the field I may, but that would be if the relationship moved from the realm of therapist/client and into one where we could call each other “friends” or “acquaintances” …I believe that as a client, it is also my responsibility not to attempt to blur any boundaries between he and I. But I do recognize that not all clients will think that way.
Hi, Karen! Welcome back! Thank you for extending this conversation to the client’s perspective and to also recognize that we all had lives before we ever put on our mental health hats! There is absolutely no reason you should delay in building that personal brand . . . and I would say that you are, my dear, light years ahead of where most of us start in our professional lives because you are already planning yours! Go for it! In fact, I think every student of mental health would be wise to begin that branding on Day One of graduate school. Good for you!
I’m curious about how you plan to reinvent yourself while looking for the right opportunity to begin work on your supervised hours. What is it you are thinking about? And, how exciting to be planning that adventure! I can’t think of any field in which you might focus that would later on negatively impact your transition into mental health. In fact, those “ancillary” experiences typically serve to better inform your clinical work and your business related work, too. So, what is it exactly that has you “muddled” right now?
You comments about appearing sterile and sanitary caught my attention because those are mistakes that I often see therapists make online. You cannot be seen as sterile and expect to forge relationships . . . with potential referral sources or potential clients. Those “relationships” will simply feel stilted and forced. Likewise, you cannot spend your energy and efforts on sanitizing your communication or you’ll go crazy and achieve similar sterile results. The research out there is clear . . . effective online communication needs to be consistent, authentic, useful, and inspiring – none of which I associate with sterile and sanitized. And, of course, as you point out . . . any effort to control anyone else’s thoughts / beliefs about you . . . is pointless.
I agree that not all clients make the same choices. In my 30 years of experience, most of my clients are wonderfully respectful of my privacy and professional boundaries. However, rules / laws aren’t made for the majority. They are made for the few who cannot / will not respect the needs of others . . . and so it is with a very few that I have worked with. Those social media policies will save you guys many hours of frustration and fear and perhaps even litigation if you have given careful and thorough consideration to them ahead of time.
The only place, Karen, that I would take exception with you is in your very last sentence. I love it when a client makes good and healthy choices related to boundaries. However, if and when a boundary violation occurs, a court (and most likely a licensing board, too) will always rule that it is the therapist’s ethical and legal responsibility (and only the therapist’s ethical and legal responsibility) to maintain appropriate boundaries. I suppose the exceptions might be if the client is stalking the client (and it has been reported to law enforcement) or there have been threats / acts of violence toward the therapist. I mention this only because it can be a dangerous and deceptive head game to ever believe (with the exception of those noted above) that the client is the reason a boundary is violated. There’s some fascinating research out there that notes that it is that very slippery slope that results in most therapists violating boundaries.
In any case, thanks for taking time to chat this evening!
I am very keen on advancing the field of animal assisted therapy which is markedly different than animal assisted activity. The benefits of using an animal as part of the intervention process can be dramatic and far reaching. This is, I believe, the culmination of my life’s work to this point. Before I was graduate school for this, I had been a zookeeper, veterinary technician, and an operant conditioning dog trainer. I have trained dogs to assist people with psychiatric disabilities and my current dog and I have worked with several people with severe issues. Yeager alerts to panic attacks, calms children with autism that are having meltdowns, and has amazing success with veterans’ severe PTSD. This is an area in which I am confident saying that I am very knowledgeable and have a high degree of confidence in my ability. (And I know that AAT is not right for everyone, but it is remarkably successful and very few people are doing it.) So that’s my “dream” I suppose.
And since supervised hours are not readily available, I am switching gears and will push to create my business plan and network with others. The other area (and AAT rather fits in there too) which I am passionate about is Autism Spectrum Disorders and Sensory Processing Issues. And really more from an acceptance model than a “cure” model.
Parents struggle with knowing how to help their children navigate their world in a more comfortable way and push very hard for “neurotypical” which is problematic for most of the children. This too is an area that is woefully under served and largely ignored.
And so if I don’t have the opportunity to work towards liscensure now, I can promote myself (and continue to build my competencies) in those areas. If nothing else, if I can get people here to allow me to help them with those clients (even in a non-therapy setting) then I will have made a difference in the lives of people who really walk a hard road. (WOW that was long winded…sorry.)
As to my last thought there about clients and their boundaries, I know that it is always “on” the therapist to maintain boundaries and I suppose my thought wasn’t expressed well. As a client myself, who does not have BPD for example, as I move into a state of more effective function, one of the things I have learned is boundaries. So, I keep my mother in law out, I don’t invade my childrens’ boundaries, and I recognize when I am becoming diffuse in a situation. And so that is what I mean by a client should also work to maintain boundaries.
I know someone who discovered her therapist was following her twitter stream and was uncomfortable. She did not want the therapist doing that, but was wishy-washy about saying anything to her therapist about it. Yes the therapist was in the wrong, but if my friend had better boundaries she would have said “Hey, no way. That’s invading my space and I’m uncomfortable.”
Likewise, I think (just as a human being) that I should be able to understand the client/practitioner relationship and not push to be friended by my therapist. I know that not all clients can/will do that and the therapist is responsible to hold the line, I am just saying that I think clients can and should be able to manage that type of issue too… not create problems for therapists, and be able to push back if they are feeling invaded. More of a rhetorical “should” state than a statement of responsibility.
I hope that clears up the misunderstanding. =D
Karen, I love that you have hit a roadblock in achieving your dream and have matter-of-factly simply backed up and taken another route! Nice job! So many of us get stuck on our paths by believing there is only “one right way” when the reality is . . . there are MANY WAYS to get there! You are a perfect example of the resilience that is required in this life to succeed!
Thank you for the clarification about responsibilities for boundaries. I suspected that might be the case but since it wasn’t completely clear, decided to take the opportunity to expound on them. It’s the area where therapists most often get into trouble. Hope you don’t mind!
Hmm…mixed feelings on this one Tamara.
I always appreciate when therapists tackle this issue as it holds unique space on many fronts, including boundaries and ethics.
I also believe a sense of humor, honesty, and transparency are essential to every clinical relationship.
Whenever I’ve found myself questioning whether to post something non-therapy related, I come back to the same mantra:
I have too much respect for my clients (including former clients) to think they have so much time on their hands that they’re going to stalk my Twitter stream and Facebook page updates. Additionally, I never want to over-state my importance in their lives.
Bottom line: Nothing online is confidential and be authentic always.
Ohhhh, Linda! Thank you so much for sharing your thoughts here! Your bottom line and mine are certainly the same. I suspect though you and I have had some different experiences that inform how we act out those beliefs.
I have been stalked – not online but nevertheless actively stalked by a client and I’ve worked with other therapists who have also had similar experiences on and offline.
I’ve also read Keeley Kolmes research on this topic and was surprised that the data she collected supported the position that a significant number (my language, not necessarily hers) of clients prefer to not know about a therapist’s personal life. I’ll try to find that article and get permission to share with you guys.
Politics, religion, and what I had for dinner . . . . Those aren’t things I’m recommending any therapist routinely share on social media with clients. I know, Linda, we aren’t exactly in sync with each other on this but I so appreciate knowing that we share the bottom line!
Have a great day!
…and I forgot to mention in the original comment that I’m also extremely selective with the clients I accept in my private practice. I tend towards the anxious”worried well” ers. I rarely take on depressed clients (I know, there’s a lot of overlap with depression and anxiety), as I’ve closely monitored and evaluated who my counseling style is best suited for.
I have great admiration for those therapists who work with PDs, psychotic, and other extremely hard to treat client issues. There’s obviously a greater risk with stalking with these populations, though this isn’t always the case.
I will check out the Kolmes research. Safety above everything.
As we say in therapy, “better to err on the side of caution.”
Wonderful discussion here!
🙂 I can so relate, Linda. After 30 years in the field, my demographics have changed as well. Grateful for the years spent with a variety of issues and individuals early on but these days I screen for and work with higher functioning clients, too.
Here you go! Dr. Keeley Kolmes’ Summary of Client-Therapist Encounters on the Web: The Client Experience.
Thank you, Keeley, for doing this research and for sharing it so generously with those of us in mental health!
What an awesome discussion! I have a professional FB page, a private/personal FB page, and a professional Twitter account. I have a social media policy thanks to Dr. Holmes, and I would have been able to do none of this without good professional support to understand how to approach these things! One thing I don’t like is Google+ – so far I can’t figure out how to avoid people from putting me in their circles. I have a personal Google+ account that has one picture on it, and once I was “added” by someone from the blogosphere that I don’t have a personal relationship with, it make me not want to even have it. If I had wanted a personal Twitter account, I might feel that I was missing out, but I’m OK with just having a professional one.
I so appreciate discussions like this because I have had conversations with a lot of people that wouldn’t touch the internet with a ten-foot pole, and with some who jump in willy-nilly. The latter scares me a lot. One thing is for sure – if you sign up for this, you have to be willing to stay on your toes and make good decisions at every step of the way. If someone has no clue how they would handle a myriad of dilemmas related to social media, they need to do more research and find good professional support before they embark rather than cleaning up big messes. This is a professional responsibility not to passively find yourself in a pickle (legally and ethically). Preparing yourself for an online presence is just as important as other aspects of preparing for this profession. Kudos to professionals who reach out when they need it and support each other on this uncharted territory. Let’s hope that everyone can get good practices in place before some kind of sad landmark case happens.
Hi, Kat! Thanks so much for adding to this discussion. My experience with Google+ is that it is actually more business than personal-focused and I really prefer it over Facebook for that reason. However, having said that . . . I am not as active on it as I could be. And, like you, I have not found a way to prevent others from adding me to their circles either – just like Twitter. Anyone got a solution for this?
I am currently wrestling with Google + to try to parse out personal/professional spheres and I too am finding it very difficult to control. (I loathe facebook and hope to dispense with it.) If I am able to figure out how to work with Google + I will write a guide for it and send it to you Tamara.
Thanks, Karen! That would be great!
I am really enjoying this discussion. I am on the cautious end of on-line living, in part because I have worked in domestic violence and sexual assault fields. However, I have joined Linked In. Even here, I had a former client want to connect. I also supervise interns who are much more involved in social media and have a big on-line presence. I have to say, that some clients will follow and potentially stalk you on-line just as they might in real life. While I wouldn’t want to be paranoid, I do think reasonable precautions make sense. I also agree that I am very strategic in what I share with clients. It needs to be relevant and useful in the context of the therapeutic relationship.
I am wondering if anyone talks about any of these boundaries in their initial session or as a part of their informed consent?
Hi, Bess! Thanks so much for dropping in today to chat!
I absolutely do and believe that ethically we should all be talking about these boundaries. Even if a therapist is not involved in commenting ever on a blog or LinkedIn or Facebook or an email discussion list or Twitter or Google+ or Pinterest . . . and even if a therapist is not using Delicious as a social bookmarking tool . . . it’s unlikely that s/he has a client / friend / colleague / family member who is out there on social media and it’s quite likely that your name and information pops us occasionally, too.
Dr. Keely Kolmes has excellent resources to share related to this issue and I would recommend every mental health professional read her work and apply it liberally in discussions related to boundaries and informed consent. It’s not that most clients will stalk a therapist online or off . . . . It’s just that it is natural for many clients to be curious about their therapists and totally unaware of the need for and an understanding of professional boundaries.
You, Bess, also bring up another important perspective that I have also encountered – and that’s for those of us who supervise students / therapists-in-training. Clinical supervisors also need to remember that just as you are responsible for the clinical work of your supervisees . . . you are also responsible for their errors in judgement on social media that also negatively impact their clinical work. Make sure you are having those social media discussions with your students and supervisees, too . . . for your own sake as well as that of your clients.