Legal Considerations versus Ethical Considerations

Whenever there are difficult decisions to be made in clinical practice, there are usually three realms that must be examined by the clinician: the legal, the moral, and the ethical. Let's look at these three areas before moving forward.

Moral

Pertaining to personal behavior as measured by prevailing standards of behavior as defined by a specified (usually spiritual) group.

Consequences for moral lapses are generally the domain of individual and group conscience.

Ethical

Pertaining to accepted principles of right and wrong as defined by a specified (usually professional) group.

Consequences for ethical lapses are generally the domain of the profession and keepers of the profession.

Legal

Pertaining to accepted principles of right and wrong as defined by the law, rather than by equity (fairness, justice impartiality).

Consequences for legal lapses are generally the domain of the legal system

At present, there appears to be somewhat of a time gap between the emergence of social networking as a current phenomenon and the legal and ethical dimensions of clinical practice related to social networks. Clear statutes have not yet been created at either the state or federal level. Because legal definitions and ethical definitions are created through a process of dialogue between groups of people serving as a society’s or a profession’s representatives, it can take time for definitions to be created for emerging concerns.

This means that clinicians must often attempt to derive their own ideas of what is right and wrong based upon their knowledge of the code of ethics within their profession and more general principles related to law and ethics. This is where things can get confusing.

To begin with, there is not always clear agreement between legal and ethical dimensions of any particular situation, let alone agreement with the clinician’s personal, moral understandings. In fact, it is possible for a clinician to act in a manner that is legal, but not ethical; or ethical, but not moral; or moral, but not legal or ethical.

As we know from the history of the civil rights movement, laws can be written and enforced in ways that are unfair and inequitable. Conversely, some very moral and ethical people have expressed their moral and ethical stances by undertaking actions that violated the law for the specific purpose of challenging the law and putting pressure on society to engage in a critical re-examination of the law.

This is a necessary process because the law is designed to be fluid and changing over time, but fixed and certain at any specific point in time. Law, in fact, oftentimes struggles to keep up with changes in ethics and morals. Leaders who are involved in helping ethics and morals to progress forward sometimes find themselves pushing the boundaries of the law - until the law can be rewritten to reflect the changes in society’s understanding of what is right and wrong.

Ethical standards, like laws, are also at least partially derived from commonly accepted moral ideas about what is right and wrong behavior, but typically within areas relevant to specific professions. The moral dimension is deeply involved in helping to shape both the legal and the ethical dimensions. Many laws, in fact, represent an attempt to codify and enforce commonly accepted moral understandings.

The important feature to know about the moral dimension, however, is that it is personal in nature. Both legal and ethical lapses can set in motion the external imposition of consequences. Moral lapses that do not also break the law or violate ethical standards will not provoke any externally imposed consequences. The consequences for moral violations will play out between the person and his/her individual conscience.

However, as we will see clinicians may be asked to submerge the moral or personal dimension to the demands of the legal or ethical responsibilities of being in this profession. This will have some bearing on what a clinician should and should not do in terms of his/her interactions with social networking sites.

The purpose of this course is to attempt to create some clarity about these issues through reference to the knowledge base that is already present in the study of ethics, pending better clarification from the law and from the codes of ethics. This study will focus on several major areas that are relevant to ethical practice, beginning with the issue of appropriate professional boundaries.


Professional Boundaries

What do you do when a current client makes a “friend” request on Facebook? How do you handle it when a former client reaches out to establish a relationship on LinkedIn? Each of these questions poses a possible professional boundary problem, depending on the therapist’s response.


Vignette1: Fred is a dedicated and effective counselor who has been in a traditional psychotherapy practice for years. He decided to accept a “friend” request from a client with whom he had recently terminated a successful long-term therapy relationship as a way for providing ongoing encouragement and support. Fred and his former client would regularly correspond through Facebook, but Fred didn’t realize that his former client was relying more and more on their Facebook relationship. Fred went on vacation to a place where he had no internet access, and therefore was unable to read or respond to the former client’s more frequent and despondent posts. The former client posted one last time, threatening suicide if Fred did not respond. When Fred did not respond, the former client committed suicide. The former client’s grieving parents became aware of the series of posts between Fred and their adult child, and as a result contacted an attorney as well as the state counselor Licensing Board.


Therapists must be mindful at all times of how their social media activities can blur the boundaries between personal and professional lives. They need to consider the possible negative impact that social networking could have on their professional relationships. How is this possible?

First, a clinician who maintains a presence on social networking sites must clearly separate private from professional lives online. Some therapists maintain two sites: one for their private, personal relationships (friends, former schoolmates), and one for their practice (promoting the practice to attract new clients, providing information for how to access the practice, etc.) In this way, clients can access the practice information where they can learn as much about the clinician as the clinician has posted on this publicly accessible site. Meanwhile, on their personal site, it is recommended to utilize the highest, most stringent privacy settings so that the therapist’s privacy is guarded as much as possible.

However, the internet does not have infallible security features, and it is important to remember that no matter how much effort is made to maintain privacy, and even if everything is done correctly, the site might still have a security breach. In this case it is anyone’s guess how many people will have access to this “private” information. And once others outside of this security net have access, there is no control over the information that they may download.

Second, it is always good practice to discuss with clients up front 1) expectations for boundaries and 2) questions related to forming online relationships. The recommended approach is to “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.” (Kolmes, Merz Nagel, and Anthony, 2011)

Because there is the potential for clients to interpret this refusal to engage in online interactions as a kind of rejection, it is a matter that must be handled with some care and preparation. Early in the formation of the therapeutic relationship, clinicians should provide to the client some education about the important purposes for retaining a professional relationship at the expense of personal interactions, and each conversation must be approached respectfully and with sensitivity.

While the maintenance of this boundary can be important for the clinician’s ability to maintain a viable private life apart from his/her clinical work, this should not be the primary element of the discussion with the client. This discussion should always be framed in terms of protecting the client’s important interests. In fact, this orientation towards the client reflects a deeper truth: the primary reason to maintain professional boundaries is to ensure that the professional relationship remains in the client’s best interest. Boundaries in helping relationships provide the structure so that there is no question about what kind of relationship it is.

With clearly outlined boundaries, a client will never confuse the therapeutic relationship with friendship or a business relationship, for example. In this way, the client improves the likelihood of gaining the maximum benefit from the therapeutic relationship, with minimal risk that the relationship will become unhelpful. Additionally, when the boundaries are crystal clear, clients are better protected from abuses of power.

This necessarily means that the professional relationship is given priority over all other relationships. Consider how damaging it could be to the therapeutic relationship for a client to see photos on a clinician’s social networking site, where the clinician is not behaving in a professional manner. If a clinician decides to maintain a presence on social media, they must remember at all times to guard their privacy by implementing the highest level of security and carefully scrutinizing all requests for access.

At a deeper level, the primacy of the clinical role also means that clinicians may have to consider imposing upon themselves a certain degree of self-censorship in terms of what they post on social media sites. Ethical conflicts might be created if a clinician chooses to post any personal information that might be deleterious for a client to see.

This is a difficult concept for most clinicians to accept. However, it cuts to the heart of some important understandings about the very nature of our profession and the ethics of being a mental health professional. The counseling profession is different from most other professions in several important - and connected - ways:

-The nature of counseling is such that great and lasting harm can be done to clients if the clinician engages in the wrong behaviors.
-Because harm can be done to clients, most states restrict the counseling profession. The only people who can practice are those who meet certain criteria and follow certain guidelines.

The capacity to do harm exists side by side with the capacity to do good. The counseling profession is defined - and thus sanctioned - as a profession whose primary purpose is to promote the well-being of its clients and the public at large, not to take care of the personal or financial well-being of the clinician.

This is different than most businesses. For most businesses, the primary responsibility is to take care of the financial well-being of the business and its stakeholders. In most businesses, the well-being of the client does not really come first. Companies may lose customers for not looking out for the interests of the client, but they will not lose their right to engage in that business. Clinicians can. Every year clinicians face ethics sanctions for honoring their personal lives ahead of their professional obligations.

This speaks to a fundamental conflict that not only affects the study of ethics, but, more importantly, affects the practice of ethics. In a situation where there is ethical conflict, how much does the clinician need to put aside his or her own interests, including the right to follow one's own values and principles, or pursue a robust personal life, in order to sufficiently take care of the best interests of the client and the public? Even clinicians who feel they have a clear understanding of ethics, can find themselves in very confusing territory.

Because the government - at both the state and federal level - and the various counseling professions work together to oversee the definition of who can practice, they also involve themselves in the clarification process around this important issue for mental health clinicians. In fact, the state and federal governments continue to clarify new understandings about what constitutes legal and ethical behavior, and make demands upon counselors to know these changes and apply them in their practice.

In addition to making these demands, the government and its sanctioning bodies, including state licensing boards, also acknowledge the different nature of the clinician's job by conferring certain special rights and privileges to the counselor. To help the trainee understand this issue - and its relationship to why certain behaviors are demanded and expected - more clearly, some time will be spent on it here.

The first special right is the right to practice as a licensed clinician, with the state acting as a kind of guarantor of the clinician's training, skills, experience, and ethical orientation. In essence, the state says that the licensed clinician can be trusted because he or she has fulfilled a certain set of standards and has agreed to act in certain ways that protect the safety of his or her clients and the public at large.

If the clinician does not meet these standards, or does not act in ways that protect the safety of clients or the public, the state can take away the clinician's legal right to practice.

The second right that is usually given to the clinician is the right (and responsibility) to maintain privileged information, in the same way and with largely the same expectations as are granted to doctors, lawyers and clergy.

This right has an important purpose: it allows clients to trust the clinician in handling important, and sometimes compromising, information. The state has a stake in creating this trust, because confidentiality allows the goals and tasks of counseling to proceed in a more effective way. But the state again becomes the guarantor of the client's trust, saying that the clinician will demonstrate the right behaviors in the use of confidential information. This includes the proper use of professional boundaries.

The third right given by the state is the right to join insurance provider networks, in a way that is overseen by the state, and to file third party insurance claims. In this way, the state acts as a guarantor to insurance panels of the clinician's ability to provide competent service.

The state may also act as an advocate for the clinician by instructing third party payers that they must offer payment for these counseling services. The rights and privileges of counseling, and the demands and responsibilities placed upon the clinician, are intricately intertwined.

One cannot have the rights and privileges without also accepting the demands and responsibilities.

Clinicians frequently struggle with the demands that are created from the responsibilities of the profession, as these demands place burdens and restrictions upon the personal life of the clinician. For example, clients may sometimes call in crisis in the middle of the night, exhibiting the potential to harm themselves or others. When a clinician chooses to become licensed to perform clinical services, he or she accepts the requirement of handling such crises, instead of simply going back to sleep.

The personal right to privacy (and sleep) can be superseded by the professional obligation to protect the safety of the client. These kinds of obligations exist as a condition of receiving the privileges of professional practice, as they do for doctors, safety personnel and many other service professionals for whom the state has guaranteed to the public the professionalism of the practitioners involved.

While the need to self-censor material on social networking sites may feel burdensome, consider the following as a point of reference. Doctors are granted rights and privileges to practice medicine that are not available to unlicensed citizens, but the government has traditionally reserved the right to draft any physician into military service at any time if there exists a need for additional military personnel during times of war or conflict.

The decision to secure a medical license carries with it these potential impositions on the private life of the physician. Mental health clinicians do not face the prospect of being drafted into military service, but the level of responsibility accorded to any clinician does carry very real ethical responsibilities that intrude into private life. Any clinician who fails to comprehend this relationship between privilege and responsibilities leaves the door wide open for ethical problems.


Confidentiality

Confidentiality is the cornerstone of the therapeutic relationship. It provides the atmosphere for clients to reveal their most private acts, thoughts, and emotions so that they can be addressed in therapy. Confidentiality is protected both legally and ethically. Professionals are expected to use discretion, even with informed consent and permission to make disclosures, both in seeking information and sharing information. Information about clients should be used only for the client’s best interests, not for impressing others or satisfying the curiosity of friends or family.

How do you handle reading a colleague’s blog complaining about clients’ issues? What do you do when colleagues start talking about clients while communicating via Facebook or Twitter?

Vignette 2: Sarah is a counselor who has recently started a full time job working at the local community mental health center. As is typical with this type of service provider, a portion of her caseload consists of chronically mentally ill clients. Sarah finds working with this population exhausting, but does not want to take the issue of her reaction toward her clients to her supervisor for fear of losing her job. So she decides to start a blog about her workaday life, figuring that if she changes key characteristics of her clients, she will be protecting their confidentiality and no one will be able to determine who they are. Several weeks after she starts the blog, Sarah’s supervisor asks her about it in supervision, and Sarah discovers that several staff members of the agency have been reading her blog entries.

Despite continuing education requirements, many practitioners cling to the belief that state licensing boards and professional codes of ethics condone sharing client information, provided identifying information is not disclosed. In fact, this is not the case at all.

Sharing personal information about a client does not respect the client’s dignity. Practitioners who engage in this practice risk exposing themselves, coworkers, supervisors and agencies to malpractice claims or potential ethics violations. (Robb, 2011) From a legal perspective, they may also be engaging in HIPAA violations.

With this in mind, it is imperative that counselors not discuss confidential client information on social networking sites. Therapists should understand that when they discuss clinical issues within their social networks in Tweets, status updates or blog posts, these messages can potentially be read by a wide network of non-professionals.

Even masked information can provide enough detail to risk identifying a client. Messages posted on personal and professional networks are likely archived and can be seen by other parties to whom they are not authorized to release confidential information.

Best practice dictates that confidential client information is discussed for professional purposes only, and only with those people who are clearly related to the clinician’s work, for example clinical supervision that is documented and takes place in a private setting. Counselors must understand that it is their primary responsibility to protect client confidentiality. This means that confidential information stored in any medium must also be protected. The basis of a good therapeutic relationship is that the client’s personal information will be held in the strictest confidence.

Practitioners need to be aware that confidential relationships do not take place in public and they must 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 must make every effort to channel these conversations to a private forum without drawing attention to the fact that they are being contacted for professional services (Kolmes, Merz Nagel, and Anthony, 2011) so as to protect the person’s privacy.

Conversely, it is the therapist’s responsibility to protect the privacy of clients as much as possible when they may not be able to do so themselves. There may be clients who are unable to manage their own personal privacy settings in such a way as to protect their own privacy. Clinicians must not build links that would expose the contact lists of these clients to the general public, nor allow connections to the clinician’s own list of personal contacts.

As it stands now, both Facebook and MySpace are allowing users to configure their “friends” into separate subgroups, so that the groups can be managed and kept separately, just as a user would keep their personal relationships separately grouped, e.g., their family would not be invited to a get together with their college fraternity or sorority. However, it is important to remember that intrusions, errors and mistakes can occur in even the best managed social sites. The only real privacy comes from never posting confidential information in the first place.



Dual or Multiple Relationships

A dual or multiple relationship exists when a therapist functions in two or more roles with a client either at the same time or sequentially. It is the practitioner’s responsibility to discuss with their clients expectations around boundaries and forming relationships online in order to avoid the development of a dual relationship. Any requests for contact through social media sites by clients is best ignored by the therapist and subsequently addressed at the next treatment session in order to preserve the integrity of the therapy relationship. It is not possible to be someone’s therapist and their friend simultaneously, without seriously complicating the helping relationship.

Examples of dual relationships could include bartering therapy for goods or services; providing therapy to a relative or a friend’s relative; or socializing with clients.

Sometimes, dual relationships are unavoidable. In these situations, it is the therapist’s responsibility to set clear, appropriate, and culturally sensitive boundaries. The relationships must be managed in such a way so that the other relationships don’t present conflicts of interest for carrying out professional responsibilities. (Strom-Gottfried, 2007)

Vignette 3: Duane is a counselor in a private practice. He utilizes LinkedIn to remain in contact with former colleagues and school chums. One day, Duane receives a request to join the professional network of a former classmate from graduate school, from whom he has not heard in years. Duane eagerly accepts the invitation and initiates an email exchange with his former classmate. Very soon, Duane discovers that his old buddy had actually reached out to him in order to become a therapy client. Duane is conflicted because he would very much like to help his friend, but realizes if he does this, that they cannot reconnect as friends.

Whenever dual relationships can be avoided, it is best for the practitioner should do so. This could include declining to participate in any activity, or online group, where a client is a participant. The problem with a dual relationship is that it can reasonably be expected to impair the therapist’s objectivity, competency, or effectiveness in performing clinical functions.

Additionally, establishing friendships with former clients could be unwise because they may need therapy in the future. Once a friendship is formed, it is no longer ethical for the client to access the therapist’s professional services. Conversely, it is unwise to provide therapeutic services to a present or former friend as it is unlikely that the therapist will be objective enough to provide effective clinical treatment.

Please note that different groups of mental health clinicians have come to different conclusions about whether clinicians can ever enter into personal relationships with former clients. The Code of Ethics for psychologists, for instance, allows for personal relationships two years after the completion of treatment, provided that great care has been taken to assure that shifting the nature of the relationship does not create any exploitation of the client. Social workers, on the other hand, are encouraged by their profession to adopt a “once a client, always a client” default position.

In all instances, for all professions, the key ethical understanding to consider is that the clinician retains responsibility for evaluating the entirety of the situation and ensuring that the rights of the client are protected, including the right to privacy, and that the client is never being exploited for personal gain by the clinician. Even where the client provides informed consent to create a personal relationship, this informed consent does not provide relief to the clinician in terms of their professional obligations in this area.

Clinicians who maintain both professional and personal profiles on social networking sites need to be aware that cultural factors may result in shared “friend” networks on such sites. For example, shared membership in cultural groups based on 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 networks or listservs. (Kolmes, Nagel, and Anthony, 2011)

Informed Consent

Informed consent involves two basic elements: first, the clinician reviews with the client, clearly and understandably, the nature of the therapy to be performed, the risks, benefits, and alternatives, any cost involved, as well as the limits of confidentiality and, second, the client has the capacity to understand the information being presented and is able to voluntarily give consent without being coerced or deceived. This way, the client has all the pertinent information so that he or she can either agree to or decline treatment. Informed consent is best reviewed during the course of therapy, as necessary.

It is during the informed consent process that the practitioner can set the expectations for how any interaction with the client will be handled on social networking sites. This is an excellent opportunity to discuss the legal risks and implications of online contact, e.g. how the clinician will document the online contact and the limits of confidentiality online. It is important to allow adequate time for clients to ask questions so that the clinician is clear that the client understands the parameters of the therapeutic relationship, and that the client clearly understands that this type of confidential relationship does not take place in public (including social networking sites).

Service recipients should be informed that, given the current state of computer technology, it is possible that computer–based communications will be seen by others who know how to intercept messages or “eavesdrop” electronically. (Reamer, 2006)

Informed consent must be obtained at the beginning of therapy, since it sets the ground rules about confidentiality and outlines the parameters for the treatment. The therapist and client can always revisit informed consent during the treatment process as circumstances change and the client’s understanding of psychotherapy develop.

Testimonials and Conflicts of Interest

Conflicts of interest occur when a clinician’s needs or interests threaten to take precedence over those of the client or otherwise impede the practitioner’s ability to carry out his or her professional responsibilities. (Strom-Gottfried, 2007) They can result in a loss of professional objectivity, interfere with the ability of the clinician to remain impartial, and hamper a practitioner’s judgment. A conflict of interest can occur in any profession, and is one of the more complex ethical issues faced by helping professionals.

A testimonial is an advertisement that uses written quotes from people to praise the good qualities of a product or service. It is a marketing tool used to gain credibility. It would be tempting for an agency or a private practitioner to request testimonials from “success story” clients for their website so that someone conducting an internet search – who is otherwise not be familiar with either the agency or the private practitioner - could get an idea of how others fared when using the services of those providers.

This works well for the likes of products sold by Amazon.com, or other online vendors. However, because a therapist deals with people, requesting clients to submit testimonials after successfully completing treatment is a conflict of interest. The clinician would be placing his/her need to market his/her practice ahead of potential concerns about the client’s confidentiality.

One of the great risks of testimonials provided by former clients is that such a posting can breach the clients’ own confidentiality, especially if they don’t use a pseudonym for online posting. Some clients may state that they “don’t care” about maintaining their anonymity, but it still warrants discussion – and it is the clinician’s responsibility to initiate that discussion for several important reasons.

As we have discussed, informed consent requires that a person fully understand the meaning and extent of their decision to assent to something. There are a number of important practical reasons why mental health practice works carefully to protect privacy and confidentiality, over and above the “stigma” of being identified as seeking out therapy.

The internet alters the discussion a client might have about therapy from something casually spoken to an acquaintance to something that is written for all to see and that cannot necessarily be undone once it is posted. Furthermore, if the client uses his or her actual name when posting a review, then it is possible that people whom the client doesn’t necessarily want to let know about their therapy experience could have access to this information.

Rightly or wrongly, a known history of counseling may have effects on career advancement choices, acceptance into certain groups, or the ability to get affordable healthcare coverage. Mental health clinicians, in their leadership role, are expected to have a greater degree of knowledge about the potential consequences that may ensure from a breach of confidentiality and make this information available to their clients.

Next, if a client remains in therapy or may conceivably return to treatment with the clinician about whom a testimonial has been written, can the effects of having written that testimonial be successfully anticipated? What happens if the therapy takes a turn for the worse – will the client feel exploited in having been asked previously to write a testimonial?

Finally, can the clinician guarantee that a client will not experience some emotional pressure to write a testimonial if asked to do so by his/her therapist? Does informed consent really exist if it is given under emotional pressure? Or will this request do damage to the integrity of the therapeutic relationship?

Vignette 4: Steven is a psychotherapist who works in a group private practice in a small town. The practice has existed for almost twenty years. The group has plenty of word of mouth business and has decided that they do not need to set up a website in order to generate more client traffic. One day, when Steven had some time between appointments, he decided to Google his practice and found several websites that listed the practice, its contact information and counseling services available. These websites also encouraged visitors to “Add a Review,” and much to Steven’s surprise, several former clients had submitted testimonials about the practice, some positive, and others not so positive. Steven recognized the name of one of the reviewers as a client he’d worked with and terminated several months ago.

It is incumbent upon Behavioral Health professionals to be alert to the possibility of these kinds of conflicts of interest. More clearly stated, it is the professional’s responsibility to remain alert to actual or potential conflicts of interest, detect and address - or avert - them.

There is one other consideration to address. Since we have increasingly moved to a digital world, it may also be worth discussing (particularly with tech savvy clients) the potential risks to confidentiality associated with a review or testimonial of their therapy experience on sites not associated with the clinician’s practice. This would include sites like Angie’s List, where consumers write reports about positive and negative experience with their use of service providers. This gets into somewhat trickier territory.

If a clinician is concerned that a client might post a negative review of the therapy experience, it would be a breach of professional responsibility to attempt to persuade the client not to post that review. This would be placing the practice needs of the clinician ahead of the rights of the client. The right time to educate the client about the risks of breaches of confidentiality on the internet would not be when the client is angrily exiting the treatment and threatening to post his/her experience on Angie’s List, as the client would likely interpret this education as self-interest on the part of the clinician.

It is clearly preferable to consider having this discussion much earlier in the treatment experience. If the clinician utilizes a Statement of Understanding / Statement of Services, it may even be wise to include this issue in that document, so that the client is made aware of these risks prior to agreeing to enter the therapeutic relationship. A paragraph addressing this issue in the statement of understanding might look something like this:

Policy for Communication via Social Media

It is the policy of John Q. Clinician not to initiate any connections with clients via social media and to decline any invitations to connect with clients via Facebook, LinkedIn or any other form of social media, or otherwise engage in internet based communication in ways that might reveal the existence of a therapeutic relationship. This policy is designed to protect the rights of each client to privacy and confidentiality. This policy will be followed both during the time a client is in treatment and after a client has discontinued treatment.

If this information is present in your Statement of Understanding, you will have an opportunity to discuss it in the first session, and to make reference to it in later sessions should it become relevant to do so.


Professionalism

When a practitioner is acting in a professional manner, one can be sure that the person is truthful, keeps promises, treats others fairly and behaves in a trustworthy manner. This translates to avoiding lying, or telling half-truths by selectively presenting facts.

Vignette 5: Annette works in a home visitation program for youth aging out of the child protection system. Her clients are working on becoming independent of their families and the protective services system by obtaining their drivers license and moving into their first apartment. Clients are able to obtain a laptop computer through the program so that they can be used for educational purposes. Many of Annette’s clients are interested in opening a Facebook account so that they can keep in touch with family and friends, whom they may not have seen for a long time. Annette coaches her clients on how to do this. Annette tells her supervisor that one of the reasons she does this is so that she can keep track of her client’s actions without having to rely on them telling her. For example, Annette reports that she has “caught” several of her clients participating in parties where photos posted on Facebook show the clients drinking alcoholic beverages, even though they are underage.


Clients who are treated unprofessionally can develop mistrust for helping professionals in general, and the end result can be damaging the reputation of not just the clinician, but of worker’s agency as well. Additionally, the reputation of the mental health profession as a whole is diminished with each unprofessional action on the part of any mental health clinician, making the task of building a therapeutic relationship just a little bit harder for all.

Therapists who discuss clinical issues on social networks, in Tweets or blog posts, must understand that these messages may be read by non-professionals. Even disguised information can potentially provide enough detail to identify a client. Best practice dictates that specific clinical concerns be discussed in face-to-face supervision or in a secure, encrypted environment.

Practitioners need to 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. Once again, it is worth pointing out the challenges of maintaining the client’s confidentiality on social networking sites, and how important it is for clinicians to be conscious of these potential ethical pitfalls.

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