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Therapeutic Ethics In The Digital Age - Page 2

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To Accept or Not to Accept "Friending"

Currently, more than 900 million people around the world-and more than 157 million in the United States-have Facebook pages, and at least some of them may be your clients. Clearly, the issue of when, or whether, to use Facebook touches on just about every clinical and ethical issue of importance to therapists, particularly issues relating to boundaries and dual relationships. Should you even have a Facebook page, and if so, how much of your private life should you show? Who should see what? Should you use Facebook's privacy settings to distinguish what you show among colleagues, best friends, family members, and old, new, and potential clients? How do you respond to clients who want "to friend" you?

Some outdated traditionalists or clueless digital immigrants disapprove of having a Facebook page at all, even if it's strictly professional-the Web equivalent of name, rank, and serial number. Frankly, at a time when virtually all successful businesses have online presences, including Facebook pages, it's reactionary in the extreme-maybe even just plain dumb-for therapists not to have at least a Facebook page, if not a full profile. A page can be strictly professional-your upcoming seminars, books, therapy center, clinical philosophy-while a profile might include your college reunion photos and all those cute pictures of your kids with their pet goldfish. As to what goes on your Facebook page-should you choose to have one-I tend to favor keeping it reasonably chaste in terms of personal details and imagery: no photos of you and your bar buddies getting sloshed, no pictures of you skiing, partying, and snorkeling off the Great Barrier Reef; only circumscribed information, if any, about your family. Nonetheless, many younger digital native therapists are far less reticent than I am, and they have no qualms about showing themselves bikinied and beaching, beer can in hand. After all, therapists are allowed to have personal lives, too, and wearing a bikini (and drinking) are perfectly legal, ethically neutral, activities.

What about allowing clients to friend you? Included in my informed consent form, under "Social Networking Policy," is a statement my clients sign: "Dr. Zur does not accept friend requests." There's little question that allowing clients to friend you on your Facebook page constitutes a social dual relationship. In therapy, there are a host of potentially sticky issues involved when deciding whether to accept a client's friend request-the stage of therapy and the nature of the therapeutic relationship, the state of the client (high-functioning professional or disturbed borderline; someone who needs clear limits or someone who can benefit from more flexibility), the meaning of the request for the client and for you, issues of confidentiality, and so on.

Allowing clients to friend you isn't always a bad thing necessarily, though it does require foresight. A colleague and old friend, for example, who's already a friend on your Facebook page, might want to see you professionally for a few sessions, perhaps to help her process her recent cancer diagnosis. It might actually be clinically harmful to take a rigid position and expel her from your friends list.

Again, the whole issue of whether to friend can be a minefield. It stands to reason that deleting a client-friend from the Facebook page could be devastating, and it wouldn't be pleasant to confront an angry client wondering why you didn't permit him to friend you, when you did allow others to. For me, it seems cleaner and simpler, not to mention less anxiety-provoking, just to say no to all clients' friend requests. You can, however, have "fans" on your Facebook page-I do.

Like other boundary issues-whether to touch a client or accept gifts, for instance-the decision about whether to friend requires clinical discernment, great tact, and perhaps some fail-safe policies in case the decision to allow a client to friend you explodes in your face.

The Ethics of E-mail

A client e-mails me, wanting to change his appointment for the following week. I swiftly respond affirmatively. I shoot off an e-mail to another client asking her if she could change her appointment to a different time. Within minutes, she responds with a one-word answer: yes. Two scheduling changes that, before e-mail, might have required hours, if not days, of phone tag and time wasted in polite chit-chat. Isn't e-mail great?

Then one morning, I check my e-mail at 9:00 a.m. and see that a client has sent me a message at 2:00 a.m., "Doctor, I can't take it any longer!!!" What do I do now? Send an e-mail back, try to call her, call her listed emergency number (not a good idea-it's her toxic mother), call 911?

Another time, a client begins an e-mail with, "I know we ran out of time last session, but there was something else I wanted to tell you," and then writes several convoluted pages, which I briefly skim through because I don't have a half-hour to read it carefully, much less respond. Later, a client e-mails me with a long account of a fight she had with her best friend-the topic of conversation during many of our sessions. I respond briefly that I'm sorry about the fight and that we'll talk about it next session, whereupon she writes a furious e-mail, expressing her anger at my "dismissive" and "callous" response. Clients often ask their therapists "quick" questions via "brief" e-mails, like, "My mother is coming over tonight. Should I bring up with her what we discussed in our last session about my brother molesting me?" or "I met this girl, she seems perfect, and we have a date later tonight. But I'm freaking out-do you have any quick advice?"

E-mail was supposed to make our lives easier, but now we may spend much of our out-of-session time on the lookout for and responding to messages from depressed, suicidal, homicidal, angry, panicky clients who want a response that minute. And if we don't, we may have to deal with the consequences later. What do we do if the client who "can't take it any longer" does commit suicide? How do we deal with the clients who become deeply disappointed or enraged with us, accusing us of "brushing them off," when we don't instantly respond to their fervid e-mails? You could argue that these people have a point. When the Internet and digital mobile devices have created a culture of speed in which instantaneous communication is the norm, why wouldn't they expect you to get back to them immediately? Don't you get a little impatient when someone doesn't respond fairly soon to your e-mails?

Again, e-mail raises the same questions of professional obligations and ethics, not to mention legal due diligence, as other aspects of therapy. The difference is that, with e-mail, we can theoretically be "available" to our clients 24/7. Are the e-mails we send or receive considered part of psychotherapy? Yes, they are, just as phone contacts with clients are considered part of the clinical process and, therefore, part of the clinical record. Do we have the same obligation to check, read, and answer our e-mails as we do to show up on time for sessions? It all depends on the policies we set in place. Many therapists put in their initial informed consent that they usually respond to e-mails within 24 or 48 hours during weekdays.

The fact that you give your e-mail address to clients doesn't obligate you to check daily or even weekly-as long as you give your client written and verbal communication about how frequently you check e-mails, whether you respond to them, and how soon. It's recommended that each and every e-mail go out with an electronic signature at the bottom-an automatic enclosure with a statement of office e-mail policy. Mine has the standard boilerplate about confidentiality, the potential for unauthorized access (noting that my e-mails aren't encrypted), and a request to the client to notify me if he or she wants to avoid or limit e-mails, with an instruction not to use e-mail for emergencies. I indicate in the signature that, unless otherwise notified, I'll communicate with the client by e-mail "when necessary or appropriate." I point out that I don't check my e-mails daily, and sometimes not for weeks at a time.

There's often something of a flurry around the issue of encryption and whether therapists should use it for reasons of confidentiality. As with all things Internet related, this is a murky subject. Most therapists use standard e-mail services, like Yahoo!, Gmail, or, for Mac users, Mail. None of these use encryption and all of them allow e-mails to "sit" in the computer's inbox, supposedly perusable by every passing Tom, Jane, or Harry. Some therapists, it's true, use a more secured and encrypted e-mail service, like Hushmail (, which requires clients to create new e-mail accounts and use passwords. Since what draws people to e-mail is its ease, simplicity, and convenience, this extra security turns off many clients. There are even fancier and far more secure telemental health software platforms, which offer not only e-mail, but also confidential video conferencing, data-storage capacity, and other bells and whistles.

Since e-mail is considered a part of therapy, the question becomes how much a part, and what the parameters are-whether you use it as an administrative convenience for scheduling appointments, commit yourself to read and respond quickly to lengthy e-mails, or engage in various levels of communication in between these poles. These questions should be determined with your clients in advance, probably in office policy and informed consent documents, as well as in face-to-face conversation. If you're willing to engage in dialogue and treatment via e-mail in conjunction with in-person therapy, it's important to discuss this ahead of time, as well as how you intend to charge for these services. Otherwise, you need to make clear how you'll use e-mail and what the limits will be. Generally, unencrypted e-mails should be limited to administrative concerns, such as scheduling and billing. Since this kind of unencrypted usage is so common among therapists, it may constitute "the usual and customary professional standard of care," which suggests some margin of legal and ethical safety.

But humans always push boundaries. Even though you may explain, multiple times, the dicey nature of e-mail privacy and confidentiality and ask your clients to limit their messages to administrative matters, some-like those mentioned above-will choose to write you lengthy, revealing e-mails anyway. If they're digital natives or even comfortable immigrants, they don't worry much about privacy to begin with. The fact is that the strictures of security experts-never use unencrypted e-mails for anything important or confidential-are pretty unrealistic, particularly in the world of therapist-client communications. Not to sound like a broken record (a simile most young digital natives won't recognize!), but unless you opt to prohibit all e-mail communications with clients, you'll have to tolerate a little fumbling around in the gray area of this issue. Just remember that even after you've had "the discussion" about e-mail and tried to clarify your boundaries during the first few sessions, you should be open to continuing an ongoing dialogue on the subject as clinically and ethically necessary throughout therapy.

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