Just when you thought it was safe…

Although previous generations probably did not swap cat pictures or tell 350 of their acquaintances what they ate for dinner, even the most seasoned among us has to pause when we think about life before social media. People use their private social media accounts for a variety of reasons and clinicians are no different. Perhaps you are looking for a new job or even a relationship through social media. Or maybe you use social media to decompress by doing online workouts and watching Dr. Pimple Popper videos. Whatever the case, the chances are good you will run into a client on social media. This article explores some of the most common scenarios a clinician will encounter and the ethical implications of receiving a friend request from a client. Here are some of the most common scenarios you will encounter in the field.

Online dating

This one is a little dicey for a few reasons, but I will cover the main two. First of all, nobody uses their real name on their profile. It is highly discouraged until you learn more about the person and decide it is safe enough to meet. Furthermore, people tend to be strategic about the pictures they post and even go out of their way to look way better than they would, say, at a therapy session. Awkward!

Raising awareness for a cause

Given the current political climate, groups of netizens rallying for a cause on Facebook or Twitter is a common occurrence. You and your client may hold some of the same causes (e.g., women’s rights or animal rescue) dear. I have even heard of a clinician learning one of their clients was the original foster home for the clinician’s beloved dog years before they sought services.

Recovery pages

Most clinicians seek out their own therapy at some point in their careers. Some are even in recovery from an addiction or mental illness and need the support of an online group. Maybe you have even suggested this to a client in a session and they took you up on it.    The most common scenario happens in the 12 Step community. Several of my colleagues work a 12 Step program of recovery and it does wonders for them. They in turn recommend that clients seek out a fellowship when it is appropriate, but will not disclose what meetings or online recovery groups they frequent to maintain their privacy and professional boundaries.

Most go the extra step of using a different first or last name on their social media accounts to be less traceable. Unfortunately, these precautions are often no match for the close-knit nature of the online 12 Step community, where participants are expected to network with other people in recovery. The client may unknowingly encounter the therapist in order to fellowship, or seek them out because they feel more comfortable with a familiar face–err, avatar. Either way, the therapist is left with the following options:

  1. Continue the online relationship with this client and keep it to themselves.
  2. Not respond to the client and hope the situation takes care of itself.
  3. Politely tell the client that although they value their working relationship and are proud that the client is seeking support, they cannot have a peer-to-peer relationship with them for ethical reasons.
  4. Stop participating in the group and find a client-free recovery outlet on social media.

Now to do a little self-reflection.  What were your thoughts when reading those options?  How would you handle that situation?

Friend requests

Visualize the following: You are checking your messages on Twitter, SnapChat, Facebook, or Instagram when you see a name that looks familiar. Maybe they even sent you a friend request.  You recognize them from your clinic, perhaps even your own caseload. What is your first reaction?

Be honest. Your first reaction most likely at least partially depended on how you feel about the population you work with and your individual clients. There is absolutely no shame in admitting part of you was flattered or even kind of happy to get the friend request. You are a caring person in a career where you cannot always expect things to go smoothly or to even see the results of your work. These little pieces of recognition can be validating. There is nothing wrong with that. What you choose to do from here, however, can have serious consequences and implications for both you and the client.

Ethical considerations for social media

Most professions in the mental health field are governed by the the American Psychological Association Code of Ethics. This code sets forth several principles, designed to help clinicians and mental health workers everywhere navigate ethical gray areas. Although social media is not specifically mentioned in the code, the APA Code of Ethics offers clinicians a framework to make the best decision for their unique situation. The most relevant principles are:

  • Principle A: Beneficence and Nonmaleficence. This principle is best summed up as “do no harm.” In the context of receiving a social media request from a client, this principle advises the clinician to consider the emotional and therapeutic implications of accepting this friend request.
  • Principle B: Fidelity and Responsibility. This principle refers to a clinician’s ability to form trusting relationships with their clients and colleagues. Any clinician who receives a friend request from a client needs to consider what their responsibilities to the client are and how cultivating a personal connection will impact the therapeutic relationship.

Clinical supervision is part of the APA Code of Ethics, and it was tailor-made for conundrums like this. A good clinical supervisor discusses ethical gray areas like friend requests and helps the clinician consider factors such as the agency’s policies on personal contact and how to deal with the situation in ways that maintain therapeutic rapport. To maximize this resource, the clinician may want to ask the following questions in supervision:

  1. How will accepting or declining this request change the therapeutic relationship?
  2. Which option creates less harm: accepting or declining the request?
  3. What is the best way to decline the request?
  4. What boundaries need to be strengthened in this relationship?
  5. Is there any transference or countertransference on either side?
  6. How should this be addressed during the client’s next session, if they are still active with the agency?

An example

Imagine that you have been working a 12 Step program for two years now.  You have daily contact with your NA sponsor and have completed Steps 1-12 twice.  Although you do not need meetings in the same way that you once did, you go to several a week and participate in online recovery groups because it keeps you focused, grateful, and grounded.  You see a client who is struggling in the same way you were a little over two years ago, so you suggest that he go to meetings.  You give him a list of meetings and online resources and encourage him to find one he likes.  His new sponsor recommends this client check out an online recovery community–the one in which you have been an active participant for 18 months.  You recognize the name, but the client does not appear to see you.  Phew!  You are in the clear for another month, until you get a private message that says, “Hey, I’m having trouble with Step 4 and you seem like you know what you’re doing.  Help?”

After you stop panicking, you bring this matter to supervision. Your supervisor helps you reason it through using the six questions from the previous section. That thought process might look a little like this:

1.  How will responding to this message change the therapeutic relationship?

This client is essentially taking the relationship into a forum where the two of you would be considered peers, rather than maintaining the power structure in your current professional relationship. This might undermine any authority you need to maintain in this relationship and weaken the rapport. He would also have access to some of your personal recovery details, which may change how much you choose to share online. Would your behavior towards the client change if they knew your deep, dark recovery secrets? How?

2. Which option creates less harm: responding to or ignoring the message?

That depends on how you respond.  Maybe you got lucky and the client does not know it is you, but how can you know that for sure? It is just as likely that the client does recognize you and would appreciate a little help from someone who knows his situation.  If the tables were turned, how would you feel if someone ignored you when you asked for help? Also, would your feelings about the help change if that someone ignored or blurred the boundaries of the relationship?  This situation can also create harm to you, if you consider the implications of the client knowing details of your recovery. The harm can come in the form of you being uncomfortable or triggered by the client having your personal information, the client using this information against you when you confront them, or even this client making a complaint to your agency due to their discomfort and shame.

3. What is the best way to decline the request?

Think about how you felt when you first found recovery: exposed, vulnerable, and uncertain.  Now imagine how much relief you might feel if you ran into someone you knew and respected at one of your first meetings. Your natural inclination would be to stick with them, right?  No matter how you set the boundary, the client may feel a little rejected or disappointed. However, as a rule, it is best to think of this as a potential teaching moment for the client and it is a great opportunity to point out how much courage it takes to seek help as you reiterate your professional and ethical obligations.

4. What boundaries need to be strengthened in this relationship?

You and your client both have a right to work a recovery program that nurtures each of you, which means you have a right to do so without having to think about work and he has the right to do so without feeling watched by his therapist. This is an excellent opportunity to practice healthy work-life boundaries, as well as reflect on appropriate self-disclosure. What does this look like for you?  Perhaps it means you find another online group, as it may be detrimental to your process if you have to censor yourself in a recovery setting. It may also mean being transparent about your concerns for each of you with the client, or even referring the client to another therapist if the situation gets too uncomfortable.

5. Is there any transference or countertransference on either side?

You did refer this client to recovery meetings because you saw something familiar in his struggle. A little self-reflection will tell you if this was just your empathy talking or if there is some unmet emotional need at play here. Two big questions to answer are: Does this client remind me of anyone with whom I have unresolved emotions? And, Has this client indicated that I remind him of anyone with whom he has unresolved emotions? Recognizing someone else’s struggle is fine. In fact, it makes you a better therapist. However, working out your personal issues through said struggle is potentially dangerous.

6. How should this be addressed during the client’s next session?

Unfortunately, there is no way to put this genie back into the bottle once you have responded to the message. Double unfortunate is the fact there is probably no way to get around responding to the message. Think about the advice you would give this client if he were in your shoes. Would you tell him to acknowledge the elephant in the room or ignore it and hope nothing happens?  You are now being presented with a chance to model responsible behavior in a relationship between two people.

Conclusion

Social media has changed the way people communicate with one another, so it stands to reason clinicians receiving friend requests from clients is a common occurrence. This creates some new ethical gray areas for the mental health field. Although it can be tempting to accept a friend request from a client, the clinician first has to make a few key decisions. These decisions are best made using the APA Code of Ethics and supervision as a guide, as well as communicating with clients about the decision you made, and why you made it.

 

References

American Psychological Association (2018).  APA Code of Ethics.  Taken from: http://www.apa.org/ethics/code/

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Amy Muscarello

Amy Muscarello

I'm a proud pet owner, writer, and kitchen mad scientist who works in the mental health industry. An observer-type since Day One, I have been interested in the social sciences for as long as I can remember. I am a 15-year vet of this industry, mostly as a case manager and substance abuse counselor, and am grateful to Time2Track for this opportunity to interact with the next generation.
Amy Muscarello