Ethical Framework for the Use of Social Media by Mental Health Professionals

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A competent practitioner working online will always adhere to at least the following minimum standards and practices in order to be considered to be working in an ethical manner.

Practitioners have a sufficient understanding of their Ethics Codes and Social Media and can integrate how they relate to professional conduct online. Practitioners are mindful that Social Media activity can blur the boundaries between personal and professional lives, and they take great care to consider the potential impact of these activities on their professional relationships.

Applicable Ethical Principles Relevant to Clinical Care and Social Media:

• Confidentiality: Practitioners understand that it is their primary obligation to protect client confidentiality and they understand that this means they must also protect confidential information stored in any medium.

• Multiple Relationships: Practitioners refrain from entering into any multiple relationships when these relationships could reasonably be expected to impair objectivity, competency, or effectiveness in performing clinical functions or if they pose any risk of exploitation or harm to those with whom we enter into these relationships.

• Testimonials: Practitioners do not solicit testimonials from current clients or others who may be vulnerable to undue influence. Since past therapy clients may return to treatment at some point, practitioners who wish to act conservatively in respect to avoiding exploitation of clients will not solicit testimonials from past therapy clients.

• Informed Consent: When practitioners conduct therapy, counseling, or consultation services in person or via electronic means, they obtain the informed consent of the individual or individuals using their services as early in treatment as is feasible, in language that is easily understood. Informed consent includes information about the nature and course of treatment, fees, involvement of third parties, and limits of confidentiality. Clients must also be given sufficient opportunity to ask questions and receive answers about services.

• Minimizing Intrusions on Privacy: Practitioners do not discuss confidential information on listservs or status updates on their social networking profiles. Practitioners discuss  confidential material only for appropriate scientific or professional purposes and  only with persons who are clearly related to their work (e.g. formal clinical consultation that is documented and that takes place in private settings, not publicly archived settings). Practitioners only include information in reports and consultations that is relevant to the purpose for which the communication is being made. Details of disclosure in the case of research or consultation should be discussed during the informed consent process.

• Initiating Professional Relationships: Practitioners are aware that confidential relationships do not take place in public and they make efforts to minimize any intrusions on privacy including, but not limited to, people contacting them in public forums (e.g. Facebook, Twitter, blog comments, etc.). They make efforts to channel these conversations to a private forum without drawing attention to the fact that they are being contacted for professional services.

• Documenting and Maintaining Records: Practitioners create, maintain, and store records related to their professional work in order to facilitate care by them or other treating professionals and to ensure compliance with legal requirements.

Social Media Interactions Which Relate to Ethical Principles:

• Personal vs. Professional Behavior on the web for practitioners: Practitioners are aware of the implications of discussing clinical issues within their social networks in Tweets, status updates, and blog posts, and they are aware that messages may be read by wide networks of non-professionals. Practitioners are aware that even masked data may provide enough detail to potentially identify a client. Practitioners understand that messages posted on personal and professional networks may be archived and seen by other parties to whom they are not authorized to release confidential information, and they adjust their behavior accordingly. Online case consultation that reflects client material, even with the record appropriately blinded, should occur in encrypted (or equivalent) environments only.

• Friend and follow requests: Practitioners are mindful of the ways that connecting with clients on social networks may potentially compromise client confidentiality or may create multiple relationships with people with whom we have already established one type of professional relationship.

• Search Engines: Practitioners let clients know whether they utilize search engines as a standard means of collecting client information, whether this is done routinely as part of care, or whether there are particular circumstances (i.e, emergencies) in which they may obtain this information. Practitioners document such activity in clients’ charts if this is an aspect of providing clinical care and/or assessment.

• Interacting Using Email, SMS, @replies, and other on-site messaging systems: Practitioners are aware that third-party services that offer direct messaging often provide limited security and privacy. Practitioners remain aware that communicating on such systems with clients may expose confidential client data to third parties. Practitioners inform clients at the beginning of treatment about appropriate ways to contact them and let clients know that if they choose to send messages on these networks, these messages may be intercepted by others. Practitioners are aware that all messages exchanged with clients may become a part of the clinical and legal record, even when strictly related to housekeeping issues such as change of contact information or scheduling appointments. All therapeutic communication should offer encryption security or the equivalent. Practitioners should define the record according to the laws of their jurisdiction and according to their defined professional scope of practice.

• Consumer review sites: Practitioners are aware that their practices may show up on various consumer review sites and that clients may perceive a listing as a request for a review. Practitioners do not ask clients to leave reviews. Practitioners understand that they cannot respond to any reviews in any way confirming whether someone is or was a therapy client.

• Location-based services: Practitioners are aware that placing their businesses as check-in points on LBS’s may allow clients with LBS-enabled devices to indicate when they are visiting their offices. Practitioners understand that this may compromise client privacy and they make clients aware of this potential exposure.

• Online treatment: If practitioners are providing telemental health services via text-based or video chat, they are aware of additional ethical requirements related to these types of care (Nagel & Anthony, 2009).

Practitioners work within their Scope of Practice.
Scope of Practice indicates the specific area to which a practitioner may practice. Scope of practice in many geographic areas also defines where a practitioner may practice; whether the practitioner may practice across various geographical boundaries and within what parameters a practitioner may practice. Practitioners also follow local and regional laws and codes of ethics as applicable.

• Understanding of boundaries and limitations of one’s specific discipline: Practitioners understand which assessments and interventions are allowed within their specific discipline. For instance, career counselors who have no training in mental health issues generally do not provide psychotherapy services.

• Understanding of specific laws or ethics within one’s own discipline or geographic location: Practitioners understand the limits set forth by laws or ethics within the applicable geographic location. For instance, in the United States, Licensed Professional Counselors cannot call themselves Psychologists, and in the UK the term ‘Chartered Psychologist’ is reserved by law for use only by those with proper recognition from the appropriate authorities. Certain states dictate what a practitioner can be called due to the implementation of Title laws. Practice laws may prevent a licensed practitioner from interpreting certain personality tests in one state, yet the same practice may be accepted under Practice law in another state.

• Respect for the specific laws of a potential client’s geographic location: Practitioners understand that different geographic regions may offer additional limits to practice, particularly with regard to jurisdiction. For instance, a counselor in the UK should be cognizant of the licensing and practice laws of other jurisdictions. For example, in the state of California the law prohibits practitioners from engaging in counseling services with clients who reside out of state.

• Competence: Practitioners understand that knowledge and facility in social media does not exempt one from obtaining training and supervision in specialized care, such as providing telemental health services.

Practitioners work within their boundaries of competence: they seek out training, knowledge and supervision. Practitioners also consult with other professionals, when appropriate.

Training, knowledge and supervision regarding mental health and technology is paramount to delivering a standard of care that is considered “best practice” within one’s geographic region and within a global context. Practitioners are encouraged to demonstrate proficiency and competency through formal specialist training for online work, books, peer-reviewed literature and popular media. Clinical and/or peer supervision and support are mandated for practitioners who cannot practice independently within a geographic region and is highly recommended for all practitioners.

• Formal Training: Practitioners seek out sufficient formal training whenever possible through college, university or private settings. Formal training is displayed on the practitioner’s website.

• Informal Training: Practitioners seek out continuing education and professional development and conferences, conventions and workshops.

• Books: Practitioners read books written by the general public and professionals.

• Peer-reviewed Literature: Practitioners read peer-reviewed literature that includes the latest theories and research.

• Popular Media: Practitioners are informed through popular media such as magazines, newspapers, social networking sites, websites, television and movies and understand the impact of mental health and technology on the popular culture.

• Clinical Consultation: Practitioners seek professional consultation whenever the practitioner cannot practice independently within his or her geographic location or when practicing outside of their area of expertise. Clinical and/or peer supervision is sought by all practitioners who deliver services via technology. Clinical and peer supervision is delivered either face-to-face or via encrypted methods.

Practitioners display pertinent and necessary information on Websites and Social Media profiles that are related to their professional practice.

Websites that provide information for the general public, potential clients, current clients and other professionals will include the following information.

• Crisis Intervention Information: People may surf the Internet seeking immediate help. Practitioners display crisis intervention information on the home page. Practitioners understand that people in crisis may visit the website from anywhere in the world. Offering global resources such as Befriender’s International or The Samaritans is the best course of action.

• Practitioner Contact Information: Practitioners offer contact information that includes email, mailing address and a telephone or VOIP number. While it is not recommended that post addresses reflect the practitioner’s home location, clients should have a post address for formal correspondence related to redress, subpoenas or other mailings requiring a signature of receipt. Practitioners state the amount of time an individual may wait for a reply to email or voice mail. Best practice indicates a maximum of two business days for therapeutic inquiries.

• Practitioner Education, License and/or Certification Information: Practitioners list degrees, licenses and/or certifications as well as corresponding numbers. If the license, certification board, or professional body offers a website that allows the general public to verify information on a particular practitioner the license and certification listings should link directly to those verifying body websites. Practitioners consider listing other formal education such as college or university courses, online continuing education and professional development courses, and conference/convention attendance directly related to mental health and technology.

• Terms of Use, Privacy Policy, and Social Media Policy: Terms of Use, often all or in part, synonymous with a practitioner’s informed consent, is available on the website either as a page on the website or a downloadable document. The practitioner’s privacy policy is also available in the same way and offers information about if or how email addresses, credit card information and client records are used, shared or stored. Practitioners must ensure that they comply with the requirements of the Data Protection Act and other aspects of applicable law, and in the United States, practitioners display the Notice of Privacy Practices to indicate compliance with HIPAA. Applicable information regarding privacy and confidentiality that is required for patient consent in the geographic location of the practitioner should be posted on the website as well. Practitioners who maintain professional accounts on Social Media sites include information about their professional use of these services at the beginning of treatment (Kolmes, 2010).

• Encrypted Transmission of Therapeutic and Payment Information: Practitioners offer secure and encrypted means of therapeutic communication and payment transactions. Email and Chat programs whether embedded within the practitioner site (private practice or e-clinic) or utilizing 3rd party platforms such Hushmail are explained on the website. Payment methods are explained as well through merchant information or information provided by the practitioner.

Practitioners offer an Informed Consent process.
The informed consent process begins when the client contemplates accessing services. Therefore, clear and precise information is accessible via the practitioner’s website. The informed consent process includes a formal acknowledgement from the client to the practitioner. This acknowledgement is received via encrypted channels. Informed Consent content is revisited during the course of therapy as necessary and beneficial.

The following topics are addressed within Informed Consent:

• The nature and course of treatment.
• Treatment fees.
• involvement of third parties and limits of confidentiality.
• Setting expectations for how practitioner will interact with clients on Social Networking sites.

• • Helping clients to understand legal risks and implications of online contact (documentation, confidentiality, etc.)
  • Helping clients to understand the unique nature of therapy relationship.
  • Clients must also be given time to ask questions and receive answers about our services.

Confidentiality and Technology

• Encryption: An explanation about the use of encryption for therapeutic exchanges and lack of encryption if/when unencrypted methods (standard email, forum posts, mobile telephone, SMS texting, social networking) are used for issues such as appointment changes and cancellations.

• Privacy Policy: The practitioner’s privacy policy is also included in the Informed Consent process including information about how email addresses, credit card information and client records are used, shared or stored. In the United States, practitioners must include the Notice of Privacy Practices to indicate compliance with HIPAA. Applicable information regarding privacy and confidentiality that is required for patient consent in the geographic location of the practitioner is included in the Informed Consent process.

Other Relevant Issues

• Cultural Factors that May Impact Treatment:  Practitioners with both personal and professional profiles on social networking sites are aware that cultural factors may influence the likelihood of discovering shared friend networks on such sites.  They are aware that shared membership in cultural groups based upon ethnicity, sexual orientation, disability, religion, drug or alcohol recovery communities, and other identifiers may increase the likelihood of discovering overlapping contacts on websites or shared email lists. Practitioners who treat other mental health professionals may also share professional space on various professional social networks or listservs.

• Dual Relationships: Practitioners discuss with clients the expected boundaries and expectations about forming relationships online. Practitioners inform clients that any requests for “friendship,” business contacts, direct or @replies, blog responses or requests for a blog response within social media sites will be ignored and addressed subsequently in treatment, to preserve the integrity of the therapeutic relationship and protect confidentiality . If the client has not been formally informed of these boundaries prior to the practitioner receiving the request, the practitioner will ignore the request via the social media site and explain why in subsequent interaction with the client. See above sections of this framework for more detailed information.

• Peer Support and Self-Help: When mental health professionals sponsor, host, partner, moderate or facilitate peer support and self-help efforts, such efforts are maintained in a secure and encrypted environment.

References

American Association for Marriage and Family Therapy. (2001, July 1). AAMFT Code of Ethics. Retrieved from http://www.aamft.org/resources/lrm_plan/ethics/ethicscode2001.asp

American Counseling Association. (2005). ACA Code of Ethics. Alexandria, VA: Author.

American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060 – 1073.

Anthony, K. & Goss, S. (2009). Guidelines for Online Counselling and Psychotherapy 3rd Edition including Guidelines for Online Supervision. BACP Publishing, Rugby

Anthony, K. & Nagel, D.M. (2009). Online therapy: A practical guide. Sage Publishing: London.

Kolmes, K. (2010, February 1). Private Practice Social Media Policy. (Retrieved October 26 2010) from http://www.drkkolmes.com/docs/socmed.pdf

National Association of Social Workers. (2008). Code of Ethics of the National Association of Social Workers. Retrieved from http://www.naswdc.org/pubs/code/code.asp.

Keely Kolmes, DeeAnna Merz Nagel & Kate Anthony

©2010 Online Therapy Institute, Inc.

Keely Kolmes, Psy.D. served as principal writer for this framework...

Kolmes, K., Nagel, D.M. & Anthony, K. (2011). “An Ethical Framework for the Use of Social Media by Mental Health Professionals”. Therapeutic Innovations in Light of Technology, Vol 1 (3): 20-29.