Counseling Today, Features

Technology Tutor: Thinking about discussing clients online? Think twice

By Rob Reinhardt August 29, 2016

Our work as counselors can be isolating at times. It is important for our professional growth, our work with our clients and our own mental health to seek peer consultation.

The internet has significantly broadened the potential pool of peers with whom we can consult. Counselors are flocking to mailing lists, forums, LinkedIn and Facebook groups to connect and learn from one another. This is a good thing! It comes with some caveats, however, especially facebookwhen the focus of a discussion is a client issue.

I hope most of us have had the positive experience of taking a client situation to a group of peers and receiving helpful feedback. These discussions might start with a brief case study: “I’m working with a young black male who is in management at his work. He has a history of anxiety that has been exacerbated recently because he feels he is being discriminated against and passed over for promotions despite his excellent performance reviews.”

This likely would be followed by questions from the counseling peer group to learn more about the situation and then a group exploration of how to proceed with the case. It’s nice to think that this discussion could take place with a large number of peers from all over the country — or even the world. Imagine gathering the synthesis of a wide array of different perspectives on this case.

The challenge on the internet is creating this scenario while maintaining client privacy and confidentiality. You’ve likely been informed at some point not to put anything on the internet that you don’t want the whole world to know. In truth, there are some areas and services on the internet that are far more secure than others (for example, electronic health records, banks, etc.). However, such high-level security doesn’t apply in places such as mailing lists and Facebook groups. In considering whether to post something about clients online, I encourage you to use the mnemonic PIT — the place where information falls in and can be discovered by anyone who happens to peer in. PIT stands for Permanence, Identity and Transferability.

Permanence

It’s important to assume that once something is sent across or stored on the internet, it’s there forever. Unless you’re operating on a private server that you have complete control over, presume there are redundant backups and other measures in place to ensure that data aren’t lost. Need a visual example? Head to the Wayback Machine and have a look at what the American Counseling Association website looked like in 1997 (bit.ly/ACAWayBack). And be aware that it is not only websites that are archived like this.

Some of us might think, “Well, if we share minimal data about this client, it won’t matter if it’s permanent.” Consider, however, that this permanence increases the chances that someone may recognize the client through your description because that information has the potential to be read for months and years to come.

Identity

In educational, employment or office settings, you are likely sitting face to face with people you know. Their identities have either previously been verified or can be verified quite easily in the moment.

Now consider online forums. Even those with the most stringent identity-verification procedures are problematic. Yes, there are professional peer groups that ask members to verify their identities and professional licenses, but few of these groups engage in authentication processes. In other words, there is no way to be perfectly sure that everyone in the online group:

  • Is who they say they are
  • Is a mental health professional
  • Subscribes to the same code of ethics and conduct
  • Agrees to hold all information posted in confidence
  • Will not make a mistake and share, forward, screenshot or otherwise cause the information posted to be viewed by someone outside of the intended audience (can you say “reading your Facebook news feed while sitting in a coffee shop?”)

That last bullet point is a big one. I don’t know of too many people who have never accidentally hit the “Share,” “Forward” or “Retweet” buttons. Even though some groups (particularly on Facebook) are set up to prevent sharing of posts outside of the group, it isn’t foolproof. And they can’t prevent things such as screen shots, which brings us to the next point.

Transferability

Almost all information posted on the internet can be forwarded or duplicated in some manner. Emails can be forwarded. Replies can be inadvertently sent to the wrong person. Facebook posts can be shared and reshared. And then there are screen shots.

Screen shots make it possible to share any type of content virtually anywhere. A screen shot of an email can be posted on Facebook. A screen shot of a Facebook post can be placed on a webpage. There’s no limit to how far and wide a piece of information can be shared.

Perhaps you’ve seen the posts on Facebook by teachers and parents who want to prove this concept to kids. They post a picture and ask everyone to like and share it so that kids can see how quickly information can travel to thousands — potentially millions — of people. Although this is a deliberate behavior, I encourage you to consider it when deciding whether to post something online.

Additional considerations

When discussing this topic with mental health professionals, their first consideration is often whether someone might recognize the client. They reason that if they leave out identifiers and keep the information general enough, the likelihood of someone positively identifying the client is small.

What I think many neglect to consider is the possibility that the clients themselves may view this information. It’s very difficult to speak generally about clients and not have them recognize themselves, particularly when they already know they are working with the counselor who shared this information.

Not convinced? As an exercise, think about how you would describe a client in a peer support context in a way that would leave that client unidentified. Now give thought to whether the client would recognize himself or herself if you shared those same details.

Psychologist and “Selling the Couch” podcaster Melvin Varghese echoed these sentiments when asked his thoughts on discussing clients online: “When thinking about asking a clinical question in a public forum like a FB [Facebook] community, I run my mind through two steps. First, I ask myself, ‘If my client saw what I just typed, would they feel like their privacy was being violated?’ Second, I ask myself, ‘If the roles were reversed, would I feel like my privacy was being violated?’ If the answer is yes to either question, I either need to make the question more general (i.e., remove anything that could remotely identify a client, from geographic location to age, gender, etc., and/or connect them to me) or leave it to an in-person consult with a colleague or supervisor.”

From a big picture perspective, I also encourage counselors to consider the public perception of mental health professionals. Even if someone can’t recognize a client on the basis of something you’ve written online, how will that person feel knowing that a mental health professional is discussing clients online? Will this change the likelihood of that person seeking help when he or she needs it? How will it change that person’s perception of counselors?

Tamara Suttle, chief inspiration officer at Private Practice From the Inside Out (tamarasuttle.com), hosts her own Facebook group and is a member of others. Although she has strict rules prohibiting the discussion of clients on her Facebook group and website, she knows that others do not. Here’s what Tamara, a member of the American Counseling Association, said about this topic: “I see [and] hear therapists talking about clients on social media almost weekly. It’s tragic really that they don’t realize how damaging this can be [not only] to their clients, but also to a therapist’s own professional reputation. I left one Facebook group for a while because of this very thing. The shocking part is that when therapists were confronted either on the group or privately, many rationalized and attempted to justify their behaviors by stating things like, ‘Therapists need a place to vent too!’ Even more shocking were the numbers of otherwise well-respected therapists who chose to remain silent on the issue.”

Ethics

To reinforce the importance of these points, we need to look at this topic from our ethical framework as counselors. The ACA Code of Ethics states that:

  • “Counselors protect the confidential information of prospective and current clients.” (Standard B.1.c.)
  • “Counselors discuss confidential information only in settings in which they can reasonably ensure client privacy.” (Standard B.3.c.)
  • “Counselors take precautions to ensure the confidentiality of all information transmitted through the use of any medium.” (Standard B.3.e.)
  • “When consulting with colleagues, counselors do not disclose confidential information that reasonably could lead to the identification of a client … unless they have obtained the prior consent of the person …” (Standard B.7.b.)

As previously noted, case consultation is an import aspect of the work we do as counselors. We typically address this through informed consent, letting clients know that case consultation happens and what the parameters are. It’s important to note the context of those consultations. Most clients are likely to understand and support face-to-face case consultations between licensed professionals within a secure office environment. But will they provide their consent if you inform them that these discussions may take place in Facebook groups? Can you ensure their privacy and confidentiality there?

To be clear, ACA representatives share these concerns, advocating for a strict interpretation of the ethics code. This includes a stance that online group forums do not constitute group supervision or consultation. ACA Chief Professional Officer David Kaplan states, “Professional counselors are ethically mandated to not discuss clients — with or without identifying information or circumstances — in public spaces, to include online spaces.”

Readers interested in exploring this further may want to pick up a copy of Using Technology to Enhance Clinical Supervision by Tony Rousmaniere and Edina Renfro-Michel. The book is published by ACA.

Legality

It is also important that counselors consider the legal implications of anything they share online. In addition to HIPAA (the Health Insurance Portability and Accountability Act), they need to be aware of any applicable privacy laws in their states.

Anne Marie “Nancy” Wheeler, an attorney licensed in Maryland and Washington, D.C., serves as ACA’s risk management consultant. “Discussing clients online can lead to potentially serious risk management and legal problems for counselors,” she warns. “Even when the information is supposedly deidentified, a client who recognizes himself in an online post could file a complaint against the counselor alleging a number of issues, including intentional infliction of emotional distress.”

Now look back at the client example I presented at the beginning of this article. It may have seemed appropriately vague at the time. But having read this article, I encourage you to give some thought to whether you would still post such information anywhere online.

Appropriate discussion

These cautions don’t mean that we have to ignore all the wonderful benefits that can result from connecting and discussing things with peers online. We simply have to give careful thought to our approach. Consider these guidelines.

1) Approach it from a “nonclient” perspective. Using our example, you might ask, “I’d like to hear experiences from those who have worked with people experiencing discrimination. What techniques and interventions have you found to be effective?”

2) When seeking someone to refer to, focus on the counselor’s skills, not the client’s issues. For example, you might say, “I’m looking for a counselor who helps clients with anxiety and also has experience working with clients experiencing discrimination.”

3) Before posting, give consideration to whether any of your clients might think you are talking about them in public and breaking confidentiality, or whether the general public might have a negative or positive view of what you are posting.

4) If you can’t be sure of protecting a client’s privacy and complying with laws and ethics, save the discussion for peer consultation in a secure environment.

As we increasingly lean on technology to carry out our work, it is important that we continue to analyze the risks and make informed decisions according to the priority of protecting our clients and their confidentiality.

 

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Rob Reinhardt, a licensed professional counselor supervisor, is a private practice and business consultant who helps counselors create and maintain efficient, successful private practices. Before becoming a professional counselor, he worked as a software developer and director of information technology. Contact him at rob@tameyourpractice.com.

Letters to the editor:ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

8 Comments

  1. Tamara Suttle

    Rob, thank you so much for addressing this topic.

    I love that you included a link to the Wayback Machine to show how easy it is to find “old” content is still alive, well, and easily accessible to all for viewing.

    I often suggest therapists put in the URL of a former iteration of their websites to see what their own words come back to haunt them.

    (I know, I know – it’s a little cruel, perhaps – but nothing serves as a better reminder that we’ve all made errors in judgement and / or at least learned over time how / when / where to do things differently and better.

    I’m sure I (and perhaps you, too?) have over-shared early on in my career.

    But, it’s articles like yours that continue to help us learn to do better.

    I appreciate your column and the consulting work you do through your blog Taming Your Practice to keep us all doing the best we can in service to our clients.

    Reply
  2. Raymond Barrett

    Rob and Tamara,

    Great points on how the risks of, and how to discern what we share on the web as clinicians. In my courses, I often share my personal experiences of witnessing clinicians whom I highly respect sharing inappropriate information on Facebook. Even the best clinicians make this mistake simply because they are not aware of what you have mentioned. In my experience when I pointed out these mistakes to peers they really appreciated me bringing it to their attention and took the posts down. I also struggle at times in training events and peer supervision to decide how much to share. I have to pause, think, and error on the side of sharing less than more.
    I think having a peer supervision group is very helpful for meeting clinicians’ need for support, referrals, and consultation. When I have things come up for me clinically, I table it in my head and look forward to the next time I see my peer supervision group. It is very important to me that I have them to rely on.

    Reply
    1. Tamara Suttle

      Hi, Raymond! Thanks for dropping in here!

      Just wanted to say that I so agree with the value of having a peer supervision group.

      It can save your sanity and your butt, too!

      Knowing I can “table” an issue to discuss with my consultation group is invaluable to me.

  3. Kat Mindenhall

    Thank you, Rob and Tamara. Tamara, I feel somehow super validated by your quote. It’s easy to be a scapegoat when you are the only therapist in a group who is shouting this from the rooftop. It breaks my heart for clients, for our profession, and for those who will be sanctioned in the future when I see this and several other questionable online behaviors by clinicians. Keep up the good work Rob!

    Reply
    1. Tamara Suttle

      Hi, Kat! Thanks for dropping in to chat! Counseling Today doesn’t have a great way to keep us informed when new comments come in so I’m just now finding these.

      Just wanted to say that I so appreciate having your ear in my professional circle of support to bounce ideas off of when it comes to these types of encounters online. You have provided me with more thoughtful feedback and encouragement than you will ever know!

  4. Deb Owens, LPC

    People sometimes get caught up on if the info is identifiable. That misses the point. Clients and the public give us their trust to protect the sanctity of our roles and the therapeutic relationship. Just as people would not want to see their dentist or gynecologist discussing clients on line its not OK for therapist to do so AT ALL.

    Reply
    1. Tamara Suttle

      Hi, Deb! Thank you for dropping in to chat about this topic. I so appreciate the Facebook group on ethics that YOU have set up to discuss these issues in a more general way. I know, I know . . . NO CONSULTATION ON FACEBOOK! (Thank you for that.)

      You are someone that I know I can seek out consultation with privately and professionally and trust to get sound advice.

      That whole idea around the info not being identifiable – at least for counselors – is very old school. Every attorney I’ve spoken with in the last 15 years says first and foremost that “If you don’t have a clinical reason for talking about the client, then don’t.” And, my understanding of “clinical reason” is that it must be in service to meeting at least one of the client’s stated goals ON HER TREATMENT PLAN. Oooops – Don’t have a treatment plan? Then you absolutely don’t have permission to discuss this client.

  5. Rob Reinhardt

    As Tamara noted, we don’t have the option of getting notified when comments are made so I am just now seeing the wonderful discussion that broke out. Thank you all for lending your voice to this topic. It’s one that I feel passionate about and I appreciate both your viewpoints and your efforts to continue to shine a light on this topic!

    Reply

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