To Friend or Not to Friend
Ethically Navigating the World of Social Media
The Inevitable Request
You're scrolling through your news feed, past the political posts by your crazy uncle, stopping to like a friend's good news, and commenting on how delicious your co-worker's homemade lasagna looks. As you search for the drooling emoji, a notification pops up. And there it is, a friend/follow request from a client. Gulp!
"To friend, or not to friend"— that is the question! And maybe you've never really considered this question… until now. Or, perhaps you've discussed this topic casually with colleagues or even touched on it during grad school— but hoped it would never happen to you.
Here's the thing: there are 2.85 billion active users on Facebook, 1.38 billion on Instagram, and just shy of 2.3 billion on YouTube (statista.com). We're talking billions of people (with a "B"), which is why the dreaded friend request from a client is bound to happen at some point.
Social media is here, and it's here to stay. These platforms allow us to communicate in business and our personal lives. Social media allows friends to connect, helps family members stay in touch, and provides efficient avenues for business networking. There's something for everyone: information, entertainment, hobbies, instant communication. Social media has altered our culture in such a profound way and has inadvertently blurred some lines of propriety.
To Follow or Not to Follow
Most clinicians have personal social media accounts. And, there are growing ethical concerns regarding whether or not it's appropriate for a professional to be friends with clients on their personal social media. There are also worries that an online relationship that begins on a so-called "business" account could easily lead to improprieties.
So the question of the hour is, "should a therapist be friends with clients on social media?" If you're a clinician and have not yet considered this question— you should, because the proverbial friend request from a client is invariably coming. The only way you may escape such a request is if you are not among the billions currently using social media. If that's you, don't skip over this discussion. Your participation and understanding are as important as that of the therapist who is an avid YouTuber.
While laws and regulatory boards do not directly speak to this issue of social media (at least, not yet), existing standards still allow us to assess compliance. Due to the subjectivity of this topic and the increase in industry-related ethical complaints, every agency should establish clear policy regarding social media.
Before we answer the question of the hour, let's explore a few key concepts.
I was recently notified that a staff person (and subordinate) was accepting friend requests from clients on her personal social media accounts. Upon investigation, it was discovered that this clinician had more Facebook friends who were clients, than non-clients. I was shocked. I simply could not wrap my brain around "why." Why would a professional counselor want to be "friends" with their clients on social media? Why would an experienced clinician think this type of online relationship was appropriate?
After hearing that my subordinate was "friends" with a whole slew of current and former clients on Facebook, without much consideration or deliberation, I saw it as a clear ethics violation with a distinct breach of confidentiality and blurring of professional boundaries. And the truth is, until my subordinate's misconduct, I had never really considered that our agency needed to address social media issues. Having a policy that addressed social media seemed unnecessary because engaging in these online relationships seemed clearly inappropriate (at least to me).
That said, this incident opened the door for many conversations on this topic with colleagues. And, as it turned out, there are varying opinions regarding this topic and several reasons some professionals might justify this boundary stretch.
So, suffice it to say that there is a rebirth occurring when it comes to the drugs of the '60s and '70s: Ecstasy, Psilocybin, and LSD. Although these drugs are still illegal, there is emerging evidence that these hallucinogenic substances could someday provide effective treatment for difficult to treat mental health conditions and addiction.
1. Legitimacy/Business Purposes
In our modern world, having an established social media platform adds legitimacy to any professional practice. In fact, a consumer may view an agency's lack of social media presence as an indicator that the organization is "behind the times," not relatable, or underequipped. An agency's level of social media presence provides a clue about the size of the organization, and many consumers associate this engagement with overall competence. In our innovative "go green" world, a lack of social media engagement may be viewed as the equivalent of not having an electronic medical record. And just as handwritten paper records are regarded as an archaic method with tremendous drawbacks, so is not engaging with clients via the worldwide web.
The internet provides infinite and inexpensive marketing opportunities. A clinical practice may establish online relationships with clients to advertise their services, announce events, provide educational materials, provide a place for clients to ask questions, etc. This way, much of the general marketing and advertising is completely free, easy to update, and gets the clinician directly in front of their clientele.
2. Building a Bond
Some clinicians may argue that engaging with clients via social media strengthens the therapeutic alliance by increasing the frequency of contact and creating a perception of connectedness. Additionally, this connectedness may foster more client honesty because their behaviors will be visible to the clinician via social media posts.
3. Collateral Information
Clients are not always honest and forthcoming (I know… hard to believe). And so, clinicians may yearn for some collateral information. There is no more accessible place to find such details than good old Google, Facebook, Instagram, etc. Many clinicians believe that it's imperative to have adequate and accurate information to execute an effective treatment plan. So why wait for a time-consuming family session or a meeting with another involved care provider to put the puzzle pieces together? Some may argue that it's in the best interest of the client (and agency) to conduct a quick and inexpensive computer search to retrieve valuable information. Interestingly, research from The Journal of Clinical Psychology shows that most (86%) of therapists research their clients online to gain more personal information (psychnewsdaily.com).
4. It's What the Clients Want
There is the realization that behavioral health/social service professionals (like you & I) do in fact work in the "service industry." Now obviously, unlike other service industries, we do not function with the same "the client is always right" attitude. Yet, we still need to be mindful of the quality/convenience of the services we provide. In short, many professionals engage in social media because they believe it's what the clients want.
Answering The Question
Let's get back to the real question: is it okay to be "friends" with a client on social media?
The short answer is, "No." In fact, despite some of the arguments in favor of online interactions with clients, my answer remains a firm, unwavering, and resounding "no."
But... Why Not?
For starters, the reasons listed in the previous section that attempt to justify interacting with clients on social media are flimsy at best. The fact is, there are much more ethical ways of accomplishing these four tasks:
2. Building a bond
3. Collateral information
4. It's what the client wants
Secondly, there is a multitude of reasons why it's not a good idea to follow clients on social media— here are just a few ethical and safety considerations:
Confidentiality is what separates the client-counselor relationship, from all other relationships. The therapeutic relationship offers the client an opportunity to safely discuss personal issues without fear of negative consequences, judgment, gossip, or criticism (basically, the opposite of what social media provides).
The parameters of privacy are so critically important that the standard of care calls for confidentiality to be explained to every client during intake and reiterated often. Every client should understand that the law prevents professionals from revealing their information to any third party without proper consent.
Confidentiality is protected by The Health Insurance Portability and Accountability Act (HIPAA) and Title 42 Code of Federal Regulations (CFR)
Part 2. The laws and regulations regarding medical privacy are complex, and a professional misstep can be costly in a variety of ways (harm to the client, complaints filed, loss of job, etc.). While HIPAA does not have rules that speak directly to social media (at least not yet), existing regulations allow us to assess compliance. For example, we should consider that HIPAA guidelines require encrypted emails and a secure text messaging solution (or an adequate security procedure to replace these measures). And let's face it, email and texts are generally more secure than social media.
We must realize that PHI (Protected Health Information) includes any health information that contains identifiers like names, telephone numbers, email addresses, full-face photos, etc. (hipaajournal.com). Further consider that if YOU follow your clients, then it's safe to assume that anyone on your account may likely be a client. Hmmm sounds like a confidentiality issue to me. And, what happens when a client hits the "thumbs-up" button? Their name is displayed among other followers, identities are revealed, and suddenly anyone who looks at your interactions knows who your clients are – including each other!
PRIVACY ON SOCIAL MEDIA? NOW THAT’S AN OXYMORON
2. Dual Relationships
At a minimum, being friends with clients on social media qualifies as a dual relationship and is therefore unethical. In the past (like way back when I went to school), dual relationships were a big "No-No." However, many agencies and professionals no longer frown upon dual relationships and contend that there are times when these unions are beneficial.
For clarity, a dual relationship is when multiple roles exist between a counselor and client. This may include:
When the professional and client are actively involved with each other in more than one capacity (social, business, etc.)
When the clinician has a relationship with a person closely related or connected to the client
When the counselor has intentions to enter into a future relationship with the client or someone closely related to the client
For the record, my opinion on this topic is somewhat "old school." I feel that dual relationships should be avoided when possible. Dual relationships are rarely in the client's best interests and often have the potential to do harm. I have found that dual relationships are almost always avoidable. So then, it makes sense (to me) to dodge this bullet by assigning a clinician that would not pose an ethical concern. Intersecting with clients in our personal lives can pose ethical concerns and threaten the integrity of the treatment experience for the client.
3. Online Security
Using private, direct messaging features on apps like Instagram or Messenger is not necessarily secure. If you are on these platforms, you already know this. You've surely received mysterious attachments or links from your own personal connections, followed by their urgent messages that go something like this: Don't open any links from me – my account was hacked! Or, don't accept any friend requests from my account – it's not me! As soon as some confidentiality has been compromised, it spreads fast and let's be honest— it's impossible to reverse.
4. Crosses Boundaries
Virtually every code of ethics requires that the clinician separate their personal and professional life. From an ethical standpoint, "social" media is meant to be a part of your "social" (not "professional") life, which is why they are called Facebook "friends." Therefore, you shouldn't invite a client to follow you on Instagram any more than you'd invite them over for Thanksgiving dinner. Allowing a client to follow you on your social media, where you share information about your "personal" life, allows them a seat in your social circle. This creates boundary issues, compromises the client/counselor relationship, and has the potential to be dangerous. Additionally, connecting online promotes a mutual/equal exchange of information, blurring the boundaries. Sharing cute pictures of your dog and your latest home improvement project with clients is simply not appropriate.
5. Personal Safety
It's not only an ethical issue but also a personal safety issue. Between location technology and people living their lives rather publicly online, a crafty person with ill intentions can easily locate you, learn your routine, or spy on your friends or family.
Behavioral health professionals should always be concerned about their safety and security— it simply comes with the territory when working with clients who struggle with mental health/substance dependence. Our clients require thoughtful and firm boundaries and we should take measures to protect ourselves, our privacy, and our loved ones. This means putting our platforms on security lockdown. Furthermore, our friends/family should also be mindful of our occupation and the need for privacy. Make sure that friends ask permission before tagging you in their posts or adjust your settings to prevent tagging.
Social Media Do's and Dont's
1. Do Separate Business & Personal
For a clinician, using social media for business purposes comes with a whole host of risks. Therefore, measures need to be taken to ensure that personal and professional lines don't become blurred.
If a practitioner uses Facebook for online marketing, it should be a proper business page. It should not be an individual profile with a professional headshot, and certainly not professional posts Monday through Friday mixed with weekend posts of your niece's birthday party, happy hour, or your trip to the beach. It needs to be a separate page or account entirely.
2. Do Establish Clear Policy
Since laws/regulations regarding this topic are broad, individuals and practices are being proactive by setting their own standards with internal policies. HIPAA may be lagging, but ethicists in the field have kept this issue from slipping through the cracks entirely. In 2014, The ACA Code of Ethics added a requirement for counselors with an online presence to distribute a social media policy.
Here are a few social media policy guidelines for organizations that operate corporate social media accounts:
All employees should be trained on HIPAA rules and training materials should be updated regularly—things change fast these days!
PHI should never be shared on social media.
Photos or videos of clients should never be shared without the client's express written consent (even if they are just in the background).
The social media policy should be discussed at intake and included in the informed consent, client handbook, etc.
Policy should outline potential risks (especially to confidentiality) and benefits posed to clients.
Social media policies should be clearly stated on any website and social media pages (American Counselors Association & Natwick, 2017).
Agencies may also require that staff members keep personal social media accounts private.
Ofer Zur, Ph.D. and Azzia Walker, B.A. of the Zur Institute suggest the following example of a "Social Media Policies" section for therapists to include as part of the informed consent or office policies given to clients prior to the first session:
"SOCIAL NETWORKING AND INTERNET SEARCHES: At times I may conduct a web search on clients before the beginning of therapy or during therapy. If you have concerns or questions regarding this practice, please discuss it with me. I do not accept friend requests from current or former clients on my psychotherapy related profiles on social networking sites due to the fact that these sites can compromise clients' confidentiality and privacy. For the same reason, I request that clients do not communicate with me via any interactive or social networking websites."
Most, if not all, of the ethical conflicts and confidentiality challenges caused by online social interactions can be averted simply by following the above-listed suggestions.
3. Do Discuss Social Media at Intake (and ongoing)
Get off on the right foot, by adequately covering this topic of "social media" and privacy during intake. Do not just assume that the client is reading the fine print contained in consents and the client handbook— review privacy policies using layman's terms. Once these policies are adequately explained to the client, a therapist can more easily say, "Thank you for the friend request, but as you know, it's against our policy." Or, "I was touched by your friend request, but I'm afraid I must keep my professional and personal life separate."
4. Don't Conduct Online Searches for Collateral Information
While it may be standard procedure to run background checks, crime reports, etc. on clients, these procedures should always be fully disclosed to the client. And, the clinician should refrain from conducting additional research on a client unless proper release/authorization is obtained. A search for (clinical) collateral information can turn into a quest that's fueled by sheer nosiness when sitting in front of Google. Personal curiosity is not an appropriate reason to snoop around on your client's social accounts. This digital detective-work fails to model the transparent communication necessary for a strong therapeutic bond. Googling a client or poking around their Facebook and YouTube channel serves as a huge time/energy-suck that doesn't work to facilitate investment in the clinical process and may compromise the sanctity of the therapeutic relationship.
5. Do Seize the Opportunity Set Clear Boundaries
Discussing social media relationships with clients is a golden opportunity to be transparent, establish rapport, and set clear boundaries. Transparency means being predictable, loyal, honest, and forthcoming, which helps to establish trust and prevent issues of contention. Establishing a healthy rapport with a client requires the clinician to demonstrate both empathy and clear and consistent boundaries. This balance between love & limits will make the client feel safe and comfortable confiding in the clinician and will promote the therapeutic relationship as a conduit for change.
6. Do Set Personal Accounts to Private
Let's turn the tables for a moment and say you've established a solid boundary between your personal and professional life, telling your clients you will not connect on social media with them. However, if your social media profiles are visible to the public, you are inviting clients into your personal life anyway. Don't misunderstand— I'm not suggesting this is justification to connect with them online. It's actually a strong recommendation to set all of your online profiles to private, so that your personal life isn't on full display for all the world to see.
7. Do Reap the Benefits
When adequate safeguards are in place, the internet provides easy, effective, and inexpensive marketing opportunities that allow businesses to advertise their services, announce events, showcase educational materials, provide a place for clients to ask questions, etc. Additionally, social media can be an excellent way for healthcare organizations to attract and interact with patients.
Late to the Party?
What if you didn't establish online policies in advance? Or take it a step further: what if you already have professional and personal lives overlapping on social media?
Don't get overly concerned that you've already made some irreversible boo-boos. Just execute an immediate U-turn. Sure, you have some backpedaling to do, but it's for the best – for you and your clients. So construct your policy carefully, then enforce it immediately and consistently.
But wait, how do you break it to clients you're already connected to online? In a word: gently, but with strong commitment. You may be rightfully concerned that an online disconnection could be interpreted as a rejection, so be mindful of the client's position before proceeding. Explain the conflict in words they will understand, and refer to your steadfast policy— voicing your full commitment to this new procedure. These strategies will help soften the blow and remove the personal aspect from the decision. Always remind them that their well-being is the most important consideration.
That's a Wrap
No one can deny we live in a digital world. It's a fixture in our business, shopping, banking, communication, and even our social lives. So if you are immersed in online activity like most of the people around you, there is no judgment here. However, like with so many things, there is a time and place. And, while the laws and ethical standards do not speak to social media explicitly, this topic is covered in many tried and true codes of conduct. So, when it comes to social media, keep your clients in the professional column and your friends and family in the personal one. Protect the confidentiality of your clients, and protect your own privacy too.
American Counselors Association, & Natwick, J. (2017, February). Ethics Update. Counseling.Org. https://counseling.org/docs/default-source/ethics/ethics-columns/ethics_february-2017
American Psychological Association, APA Committee on Professional Practice and Standards. (2021). Guidelines for the Optimal Use of Social Media in Professional Psychological Practice. Retrieved from https://www.apa.org/about/policy/guidelines-optimal-use-social-media.pdf
Ethical Framework for the Use of Social Media by Mental Health Professionals. (2020, April 23). Online Therapy Institute. https://www.onlinetherapyinstitute.com/ethical-framework-for-the-use-of-social-media-by-mental-health-professionals/
Good Therapy Editor Team, & Raypole, C. (2019, September 10). A Therapist's Guide to Ethical Social Media Use. Good Therapy. https://www.goodtherapy.org/for-professionals/marketing/digital-marketing/article/therapists-guide-ethical-social-media-use
Heingartner, D. (2021, November 4). Do Therapists Google Their Patients? This New Study Finds That Yes, 86% Of Them Do. PsychNewsDaily. https://psychnewsdaily.com/do-therapists-google-their-patients/
Younggren, J. N., & Harris, E. (2010). Risk Management: Some additional thoughts on social networking. National Psychologist. Published.
Z. (2021, July 8). Social Networking, How to respond when clients send "Friend Request" to their psychotherapists or counselors. Zur Institute. https://www.zurinstitute.com/socialnetworking/