Hardcore Twitter user Keely Kolmes, PsyD, has seen her share of mental health professionals violating patient confidentiality online. One therapist she followed on Twitter, for example, posted a "Client Quote of the Day." Another "checked in" at a bridge on Foursquare where she was doing exposure therapy with a driving-phobic client.
"That really startled and shocked me," says Kolmes, who in 2010 was one of the first psychologists to develop a social media policy for her practice. "I thought, 'Anyone could come by this location now and view you with your client.'"
Psychologists, it seems, are no different from many modern communicators who seek support or celebrate victories by posting the ups and downs of their workdays on Facebook, Instagram and other social media sites. But what's genius for celebrities who want to promote a TV show comes with additional caveats for professionals or students in fields where confidentiality is fundamental, experts say. In many cases, it's disrespectful, unethical and legally risky to talk about a client or a patient participating in a research study publicly, even in vague terms — and colleagues and friends can conceivably decipher whom you are talking about.
"Even if we just say, 'I had a great session with my 3 o'clock,' we may not realize that someone who is following us knows who sees us at 3 o'clock on Mondays, let alone stop to think about how the 3 o'clock client feels about it," Kolmes says.
Psychologists and students who reveal too much probably don't realize they may be visible to clients or research participants via Facebook or connected to their acquaintances. But Kolmes's research and experience suggest they are. In a 2012 study in Professional Psychology: Research and Practice®, she and Daniel Taube, PhD, JD, surveyed 227 mental health professionals on whether or not they seek or find clients on the Internet. More than a quarter of their sample (28 percent) reported an accidental discovery of client-related information on the Internet, such as seeing a client's tweet re-tweeted by a mutual contact, or noticing a client's post appearing on a friend's Facebook timeline.
Keeping patient contact professional is one reason why students should learn early on how confidentiality applies to social media, says APA Ethics Director Stephen H. Behnke, PhD, JD, MDiv. Sharing client information is acceptable only in very limited circumstances and for legitimate purposes, such as to collaborate with another provider in a treatment or to protect safety, he says.
"Whenever a psychologist, or a trainee, is sharing information, they need to ask, 'Why am I making this disclosure?'" Behnke says. If it's simply to share experiences with friends and family, you're not maintaining the field's professional and ethical standards. "It's a wonderful thing to share your day," says Behnke. "But how you do that if you are a basketball player, and how you do that if you are a psychologist, look very different on the ground level."
At least one psychology department has already confronted a case of bad judgment via social media. Earlier this year, the University of New Mexico reprimanded psychology professor Geoffrey Miller, PhD, after he tweeted a derogatory comment about overweight applicants to graduate school.
Miller, a tenured professor at the school who was serving as a visiting professor at New York University at the time, is now barred from serving on any UNM committee involving graduate students' admission and must help colleagues develop sensitivity training on obesity.
But psychology isn't the only field facing confidentiality violations and unprofessional behavior on social media. In 2006, physician Katherine Chretien, MD, of the Washington, D.C., Veterans Affairs Medical Center, began reading medical blogs and noticed that bloggers in her field were occasionally making disparaging comments about patients, or sharing complaints about patients or their jobs.
"Reading some of the blogs, I could see potential issues with privacy and professionalism," Chretien says. "There were lots of descriptions of patient encounters where I felt like the patient could be identified by someone."
Three years later, she published a survey of U.S. medical schools on students' online behavior in the Journal of the American Medical Association, where she and colleagues found that 60 percent of schools reported students posting unprofessional content, which included sexually suggestive material and discriminatory language. Thirteen percent of schools reported incidents that violated patient confidentiality.
Many students, of course, are not aware that they could be harming patients — they see their online communications as simply expressing themselves the same way their friends in other fields do. But such actions can have consequences. In 2009, for example, the University of Louisville dismissed student Nina Yoder from its nursing school after she blogged about the details of a childbirth she attended as part of her training. Yoder sued the university, claiming that it had violated her First Amendment rights. She won her suit and was able to graduate from the nursing program. But the university, which argued that her blog post had violated its honor code and confidentiality agreement, appealed the decision. Eventually, district courts found that the confidentiality agreement was not unconstitutional, and Yoder received no damages.
In a similar case in 2012, the Minnesota Supreme Court decided in Tatro v. University of Minnesota that public universities can restrict the speech of students in professional programs when the program has rules about professional standards. The university put Amanda Tatro, then a student in the mortuary science program, on academic probation for the rest of her time as an undergraduate for making disrespectful comments on Facebook about a cadaver she was dissecting for her anatomy class. They also gave her a failing grade in the class.
'The client from hell came in'
With social media evolving so quickly, even seasoned professionals may not know when they are crossing unprofessional lines or how to warn students against doing so, says Michael Roberts, PhD, a professor in the clinical child psychology program at the University of Kansas, who helped draft his program's social media policy.
"Like a lot of ethics, hard and fast rules are mere guidance, but then there's how you apply it to a specific situation that may not be exactly the same," he says. In other words, just because your supervisor or professors didn't specifically tell you not to talk about a patient on Facebook, recall a research participant's health challenges in a post, or tweet "just saw a trauma case" doesn't mean it's not off limits. Even faculty members who are active on social media aren't able to predict every way a student could wade into murky ethical waters.
In a 2013 article in Professional Psychology: Research and Practice on social networking ethics, authors Daniel G. Lannin and Norman Scott, PhD, of Iowa State University, wrote that today's students are particularly at risk because they use social media more than their supervisors and have more experience with new and emerging technologies. In addition, "It is also possible that older psychologists … may not be adequately equipped to address many of the emerging online dilemmas that are occurring with their younger colleagues and trainees due to their lack of experience with the new technology," they wrote.
In follow-up research to her JAMA study, Chretien found generational differences in what younger and older medical faculty considered unprofessional online behavior. For one, older faculty were more likely to view any description of a patient encounter, even in favorable terms, as unacceptable (Academic Medicine, 2011). "It's important for students to keep in mind that their post could be viewed very differently by other generations," she says.
In another study, she found that while medical students opposed policies that restricted their online behavior, they also craved more guidance (Academic Medicine, 2010).
For his part, Jeff Cain, EdD, a professor at the University of Kentucky College of Pharmacy who has published several papers on e-professionalism, tries to educate his students by showing them faux Facebook pages with examples of unprofessional posts that badmouth a profession or disrespect patients, such as "Pharmacist = highly paid individual whose primary job is to hand out drugs to f***in' idiots and put up with their s**t!" Cain urges students to be particularly mindful about their "invisible audience" — the people they have forgotten they are friends with, friends of friends and even people they may become friends with in the next year who might read their old content.
Roberts offers a similar lesson to his students and supervisees, warning against mocking clients or posting other careless prose such as "'Boy, have I had a day! It was like the client from hell came in.'"
Listservs are another online forum where too much information sharing can be problematic for psychologists and trainees, says Pepperdine University psychologist Carol Falender, PhD, co-author of the APA book "Getting the Most Out of Clinical Supervision: A Guide for Practicum Students and Interns." She has seen people compromise a patient's confidentiality when seeking referrals via online message boards that are frequented by other mental health professionals.
"People will say, 'I need a referral for a child who lives in such and such city, the mother's a professor and the father is a lawyer and the child is biting, I think there might be abuse involved and I just need a therapist who can see them,'" she says. "But this is on a network that goes out to hundreds of people, and it's identifiable."
There's an art to masking client information for educational purposes or referral requests that goes beyond changing a client's sex or age, says APA's Behnke. He advises students to ask supervisors or faculty for advice on how to do it if they aren't sure. "It's easy to give enough information that does not disclose identifying information and still gets you what you need," he says.
Those doing research that involves patients seeking treatment should also be mindful of confidentiality, including those who are doing research through such websites as PatientsLikeMe, where patients publicly share information about their treatment.
"Because an individual chooses to share information does not in any manner alleviate a psychologists' responsibility to treat that information in an ethically appropriate and respectful manner," Behnke says.
In the end, says Roberts, students and psychologists alike need to recognize the reach of social media. "People always need to question themselves, 'I have this power to do all sort of things [on social media] that we didn't have before — but should I?'" says Roberts.
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