A Psychotherapist's Guide to Facebook and Twitter: Why Clinicians Should Give a Tweet!

A Psychotherapist's Guide to Facebook and Twitter: Why Clinicians Should Give a Tweet!

by Keely Kolmes
Dr. Kolmes offers firsthand insights into the uses of social media as a professional tool.

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It seems strange today, but when I was a graduate student, nobody brought a laptop to school. I was lucky if my practicum sites had a computer that the office administrative assistant might permit me to use. I was the intern in the group who would beg whoever was working at the front desk to let me sneak on during our lunch hour so that I could check my email, write a quick blog post, or see what was happening on BMUG (Berkeley Mac Users Group). This was in 1998, which seems not very long ago, but which was eons ago in cybertime.

I’d been on the Internet since 1993, and I’d been a computer consultant for almost as long. By the time I enrolled in my PsyD program in 1996, I’d Internet dated, I’d connected with friendly folks across the country, and, I’d been on Craigslist when it was just a small email list sent out by Craig himself. I accessed Usenet before the World Wide Web was browsable, and
I spent much of 1994 lurking on support boards for polyamory and multiple personality disorder just because these forums allowed me to be a virtual fly on the wall and learn about the experiences of people whose lives were very different from mine.
I spent much of 1994 lurking on support boards for polyamory and multiple personality disorder just because these forums allowed me to be a virtual fly on the wall and learn about the experiences of people whose lives were very different from mine. The Internet was still a place that offered anonymity at that time, a land of pseudonyms and no powerful search engines to track the gingerbread crumbs back to your door. I can still remember what it sounded like when my 2400 bps modem connected to AOL: the distinctive sound of rubber band meets static as the modems on each side negotiated their connection.

I also remember becoming a psychology trainee a few years later and listening awkwardly when supervisors and professors spoke with confidence about people who were addicted to the Internet. Many of them made assumptions about those “Internet people." They were lazy couch potatoes who never left the house, or worse: antisocial porn addicts.
I seemed to be entering a field in which maybe my own Internet habits were a bit suspect.
I seemed to be entering a field in which maybe my own Internet habits were a bit suspect.

It’s now 2010 and it’s rare to find someone who isn’t on the Internet in some fashion. While many therapists may not have a social networking presence, most have email addresses and have used the Internet to locate a business, view a family member’s photos, or to watch a funny video on Youtube.

When I started my private psychotherapy practice in 2008, I made the shift from using the Internet for my personal life to using it in my professional life. An integral part of that shift entailed creating a website and a blog. In 2009, I expanded my professional Internet presence to include a Twitter account and a Facebook page for my private practice. Some other mental health professionals have been doing the same. It’s certainly a new era.

What is Social Media?

Social media is the use of web-based technology that allows the exchange of user-generated content. Such phrases probably sound like a foreign language to non-techies. So what this means in English is that ordinary people can create, share, and comment on information on a variety of platforms. They can interact with content on other user’s pages, and they can participate from both their computers and mobile devices. Two of the more popular social media networks that are appealing to mental health professionals are Facebook and Twitter. This article will focus on both of these sites.

What is Facebook?

Facebook is the most popular social media website (over 400 million users at this time, and growing daily) and it’s where I will later write "I made a dent in that article I’m writing!" in my Status Update for all of my friends to see. It’s also where I’ll get a stream of lots of information from many of my Friends—I’ll get into the issue of "Friends" below, but suffice it to say that while there is overlap between Facebook Friends and real-life friends, they are not necessarily one and the same. Some of the information I will see from my Friends might be useful, some might be funny, and some might be completely meaningless. One of the learning curves of Facebook is finding out how to cull the information you find most useful and hide the rest.

The main page of your Facebook profile is called a Wall and depending upon the privacy settings you select (which might limit who can post on your Wall, or who can even view the Wall itself) people can view things you post to your Wall or post items of their own onto your Wall. The sorts of things that get posted include Status Updates, which are brief comments you add about what you’re doing or something you care about. These Status Updates show up on the News Feed which is a constantly refreshing stream of what only an extremely social person could consider news: John just Liked a photo, Penny wrote on David’s Wall, Molly posted four pictures to Flickr (a photo-sharing site), Evan just overheard something funny. People also share news articles and Youtube videos or longer Notes, which are essays they write (or essays someone else wrote that someone wants to Share).

Some people post incredibly personal updates on their Walls. I have been surprised more than once to learn of engagements, deaths, and divorces via Facebook Walls.
Some people post incredibly personal updates on their Walls. I have been surprised more than once to learn of engagements, deaths, and divorces via Facebook Walls. I sometimes discover this information reported on Facebook before ever getting a note or phone call from the person who posted the update. People have also used the Wall to share information about missing persons in their friend networks. News can travel fast, especially when people click the Share button and immediately are able to take a post from one user’s Wall and transmit it to everyone who reads their own Wall. When you have friend networks of 100–1000 people, you can imagine how this has become quite a tool for disseminating information.

This quick circulation of information has inspired some therapists to consider using Facebook as a platform for advertising their practices. Some do this directly from their Facebook profiles and others have created a separate business listing, known as a Page. If you can get friends, families, and strangers to Like your page (prior to April, 2010, they became a Fan of your Page), then others in their network can see this action and click through to your business to learn more.

Other therapists first get onto Facebook because they want to view family photos or find friends from high school or college. It’s a social networking site allowing you to connect to your friends and interact with them and their online profiles in a variety of ways. Where Facebook gets tricky for mental health professionals is that it is a personal space that exists in public.

Personal vs. Professional Space

Our personal activities are not subject to the ethics code of our various professions. However, if you use your Facebook profile to establish your professional identity or to attract, connect, or interact with potential or current clients and colleagues, your Facebook presence has become part of your professional space. This means that legal and ethical provisions may now apply to your online activities. Be aware that professional relationships come with legal and ethical responsibilities that do not cease to exist just because you are on a social networking site.

Managing Friend Requests

If you have a Facebook profile, it’s simply a matter of time before you also start receiving Friend requests. Some of these requests may come from people you know well, some may come from people you’ve met on a few occasions or those who you’ve exchanged a bit of email with in the past, and others may come from complete strangers. Be cognizant, if you are setting up a Facebook account for the first time, that depending upon your privacy settings, you may be making personal information, such as your phone numbers, address, or email addresses public or viewable by folks you add as a Friend. It is worth thinking through who you want to be able to link to you as a Friend, and which email address you wish to associate with your account. If you choose an email address that others know, they can very quickly find your profile. Some people who prefer greater privacy manage this by using an email address for Facebook that is not known to others, to minimize the possibility of showing up as a recommended Friend when other users search for people to add.

Some therapists using Facebook have received requests from their current or former clients to add them as Friends. It is wise to think through how you plan to manage Friend requests from clients. Be mindful that inviting clients to your personal profile can be perceived as inviting them into your personal life. This can send mixed messages to clients, especially if they are unclear about therapeutic boundaries to begin with.
If you would never think of inviting a client to a cocktail party at your home with your friends and family present, then you may want to think twice about inviting them to be your Friend on Facebook (or approving their Friend requests).
If you would never think of inviting a client to a cocktail party at your home with your friends and family present, then you may want to think twice about inviting them to be your Friend on Facebook (or approving their Friend requests). It can be the online equivalent of inviting them into your social circle. It may also make them wonder who else in this social circle is in treatment with you. If clients try to add us as Friends on Facebook, or we try to Friend them (yes, thanks to Facebook "Friend" has become a verb)—even by either of us accidentally clicking on a link to invite everyone in our address book—the boundaries can become even more complicated. This suddenly brings up issues of confidentiality, dual role conflicts, and feelings of trust, boundaries, safety, and rejection. It can also create questions about whether you are responsible for attending to the information a client shares on her own profile and utilizing it in treatment.

Friends You Share

Facebook encourages us to socialize. We are given suggestions about whom we should consider adding to our circles and this includes friends, family members, and co-workers, creating a virtual filing cabinet of all of the people in our lives. So, don’t feel socially inadequate or shocked because your niece has 642 Friends! The transparency of all of these collected contacts is creating new challenges for those of us who engage in confidential services. Having Facebook profiles that are visible to our clients potentially exposes lists of all of our relationships to those viewing it. When someone who is not a linked Friend of ours on the network views our profile, Facebook shows a list of the Friends we have in common. There is no way to hide this information from being shown to others. Maybe we don’t want our clients viewing our lists of Friends, particularly our Mutual Friends. By making visible what were formerly invisible threads between us and everyone else, Facebook takes our friend networks and opens them up like a Rolodex. This is not especially containing for many people. Imagine how you or your client may feel when you discover that you have 20 Friends in common. This possibility is not so far-fetched—particularly if you are a member of a small community or if you share some other cultural group affiliation with your clients such as membership in groups related to sexual orientation, religion, disability, ethnicity, sobriety, and so on.

Pages vs. Profiles

Facebook offers the ability to make Pages instead of Profiles. Pages are similar to Profiles, but they are used more for businesses or public figures. The benefits to having a Page for your practice are that it’s a one-way relationship with those who Like your business (Liking a business allows users to add it to their Profile as something they like, endorse, or follow, and they can promote it to their Friends), rather than the two-way relationship that a Facebook Friendship implies. You can keep all of the information on the Page strictly professional and have a separate Profile that’s more personal in which you lock posts and select privacy settings to keep strangers from viewing your more personal interactions.

The biggest problem with having a Page is that you will still have to decide how you feel about who Likes your practice. Will you want your family members listed on that Page for others to see? Will you accept current or former clients as people who endorse your Page? Having or allowing your clients to be connected to your public professional profile brings up issues of confidentiality. There is also the question of whether someone Liking your Page could be perceived as a testimonial. All Ethics Codes for psychologists, marriage and family therapists, and social workers prohibit us from requesting testimonials from current clients due to their being vulnerable to our influence. Is a Facebook Page a passive request for an endorsement or testimonial? This is one of the gray area questions that social media is raising for clinicians.

So What is Twitter?

Twitter is that site where people post short messages of 140 characters or less. It’s called micro-blogging and it’s one of the things that some people say is causing our attention spans to shrink so that we’ll soon only be capable of absorbing pea-sized morsels of information. If you narrowed down Facebook to just the Status Updates and limited these updates to 140 characters, then you would have Twitter--except people can’t post things to your Twitter profile. All of your activity stays on your own page on Twitter.

Why, you may ask, would someone want to share 140 characters of information? Well, it’s a great way to direct people to news stories or make short announcements. Most people use it to share tidbits from their day and there are a lot of mundane Tweets about people’s life activities. But Twitter can get a lot more interesting if you search for news items or want to follow a conversation. For example,
some people have noticed that Twitter is the first place that they can find out if there was an earthquake in the San Francisco Bay Area and that those updates sometimes refresh more quickly than some of the well-known earthquake websites.
some people have noticed that Twitter is the first place that they can find out if there was an earthquake in the San Francisco Bay Area and that those updates sometimes refresh more quickly than some of the well-known earthquake websites.

If you’re presenting at a conference or offering a CE workshop or you have openings in a therapy group, Twitter can be one way to get that information out to your Followers. Yes, your Followers. That’s the cultish name Twitter gives to what others might refer to as subscribers of your content. When you sign up for a Twitter profile, you can start looking for others whom you might want to Follow, as well. You can search your address book to see if people you have exchanged email with are on there. This means that friends, family, and that random person you bought a futon from on Craigslist ten years ago will all show up if they have a Twitter account and if they’re in your contact list on your email account. But you can also browse Twitter’s suggested users to find people Tweeting on the topics you care about, and there are also Twitter directories if you want to search for more specialized information.

You can also have conversations with people on Twitter. You do this by @replying them. Your responses will show up on your Twitter profile page, and people can look at their @replies to see if others have responded to their messages. Twitter offers the ability to have either a public or private profile. Private profiles mean that only people you approve get to see your Tweets. If you have a public profile, anyone can read or reply to what you’re posting. Twitter also employs hashtags, which help people to find and follow conversations about a particular topic. Sometimes, people at a panel at a conference will assign the panel its own hashtag. For example a speaker may say: "This session has the hashtag #facebook_psych." When the hashtag is given, you can add the hashtag at the end of your Tweets so that others can click on it to find other public Tweets from people in the session. It also allows people outside the session to still participate in the conversation or ask questions of those who are there.

Why Would You Have a Professional Twitter Account?

I had been on Twitter with a private personal account since 2006. It was an online space I inhabited with comfort. But it took an accidental fumble for me to realize how important it could be to create a professional account and keep it separate from my personal account.

My awkward moment occurred when I tried to use my friend network to publicize my practice on Twitter. I Tweeted on my locked, personal account that I was running a support group. A friend Retweeted it to his group of several hundred followers. While I appreciated his publicizing it to so many people,
I felt exposed and I realized that I didn't want my online pseudonym linked to my private practice.
I felt exposed and I realized that I didn't want my online pseudonym linked to my private practice. I called him and explained and he deleted it immediately. This was how I recognized that maybe I couldn't have it both ways: using social networking to expand my reach but not allowing people to repost things. I wondered if it was time to create a Twitter account solely for my professional practice. But I wasn’t sure if anyone would be interested in what a psychologist had to say on Twitter.

Weeks later, in February 2009, I met with a friend for one of our co-working dates and I batted the idea of the professional Twitter account back and forth with him. Within the hour, I created my @drkkolmes Twitter profile, used it to link to a few of my blog posts, and then sent an email out to a bunch of friends. In the email, I let them all know that I would not be following friends back on the Twitter account, as it was my intent to only follow other mental health organizations. But I asked if they would be kind enough to follow or publicize the account to others. About 15 people did.

That’s how it began.

By the end of 2009, my Follower count was over 800 people, and more importantly, I’d forged a number of fruitful collaborative projects with other mental health Tweeps (people who Tweet) on Twitter.

Branding & Marketing

It may be a bit unusual to think of "branding" yourself as a therapist. After all, many of us entered this profession with the primary goal of helping others. But the reality is that we are also running a business—which means we also have to manage and market it. The best thing about using social media is that it’s a great way to improve your branding. One way to do this is to create a name for your product, even if it’s simply Dr. So-and-So. You want the people who are searching for a therapist (or for you, specifically) to find justification to trust your professional services and identity. In order to brand my product, I use my professional name, Dr. Keely Kolmes or @drkkolmes, any time I want to create an impression in a public space as a professional. Some professionals blur their personal and professional lives online. But, in my opinion, people who are trying to create a brand should be careful about using their professional name and attaching it to non-professional postings about the weather, food or other personal topics.

I make sure to only use my professional name to post psychology related news, news about my practice, or to respond to others who are talking about these matters. I want to be sure that people know what to expect when they see my name float across their screens, and what I’d like them to expect are thoughtful posts about professional topics of interest to me. I also want them to think of me when particular subjects come up that are related to my expressed interests, since then, they can also alert me to these items if they see them first. Occasionally on Twitter someone may Tweet: "@drkkolmes, you might want to see this post about therapists Googling their clients," and I am pleased that they are sharing something interesting with me. But I’m especially pleased that they know what my professional interests are and that they can quickly let me know where I can find out more.

Professional Collaborations

Social media can help you do more than simply brand your own product. It can also help you connect to other professionals who share your interests. Once you find others through a site like Twitter, you can read their blogs, have public conversations with them, or DM (direct message) them or email them and have private exchanges. It never ceases to amaze me how quickly and fruitfully Twitter enhanced my professional life. People usually assume I use Twitter as a way to try to get therapy referrals or to disseminate information to my clients. But in my experience, no referrals have ever come from Twitter. Instead, it’s been a way to build dialogues with other mental health professionals, far and wide. I’ve been able to connect with other providers who also use social media through Twitter, draw them to my blog and writing, and find others whose writing and perspectives are meaningful to me. With several of these people, without ever having met face to face, we have shared joint projects. I’ve found myself being interviewed, co-authoring pieces, and speaking at professional trainings, all via Twitter.

Transparency

Those of us who use social media talk about a move towards greater "transparency" in healthcare. What we mean by transparency in this context is that we are using social media to provide clear, accessible information about our businesses and our business practices. My website provides a forum in which I can be clear about how I work, my fees, my office policies, and my professional interests. I have placed all of my private practice forms on my website so that they are always available to my clients. This has been both a matter of convenience and a way to take a good part of the mystery out of the business and process of psychotherapy for consumers of psychotherapy services.

I blog about psychology-related topics that interest me. Since I do not allow comments on my blog and I do not wish to spend my online time moderating comments or worrying about the identity of people posting on my site, I invite readers to comment via private email and on Twitter. Oftentimes, people will Retweet my blog posts on Twitter or briefly respond to them and we might have a brief chat about it.

Another example of utilizing social media transparency is my Facebook Private Practice Page which I experimented with last May and later disabled the following April. I never had clients become Fans of the Page and I was fairly clear in my policies and blog posts that I felt this would be a confidentiality concern. But I finally decided the Page provided more risks than benefits. I discussed my reasons to disable it (summarized below) on my blog and on Twitter. In this way, social media through blogging, Facebook posts, or even Tweets can provide a platform to convey your thinking on topics when it may not always make sense to bring these topics into each and every therapy session. But it makes your process of thinking about such things available if and when clients get curious to know more about how you came to particular decisions. I did a similar thing with the development of my Private Practice Social Media Policy, blogging about it as I wrote it, so that those who cared to could understand how I came to my conclusions.

Cautionary Tales

Facebook Challenges
The biggest potential problem with Facebook tends to be around managing Friend requests and controlling who posts on your Wall. Clinicians vary on their attitudes about handling Friend requests. Some feel strongly that it’s important to welcome any clients who want to endorse their Pages. Others feel strongly that it’s a huge HIPAA, confidentiality, and dual-relationship can of worms, which isn’t worth the potential headaches.

When I experimented with my own Facebook Page for my private practice, I was very clear that I would not allow clients to become Fans or to Like the Page. This invited criticism from other professionals who felt I was conveying mixed messages by having a Page that clients could not Fan if they wished to do so. My office policies stated that I would remove clients if they became Fans and some professionals expressed concern that this could be experienced as hurtful and rejecting to my clients and that it was too harsh a response.

Ultimately, I chose to delete my Facebook Page because monitoring the Wall postings and scanning to see who had followed the Page felt like more time and energy than I wanted to spend. It was time spent on worry and risk management, rather than pleasure. Ironically, I never had a single negative experience with clients on my Facebook Page, but I did have a couple of situations in which supportive, well-meaning friends posted comments that were too personal for my own comfort. This is always a risk on any social media page that allows others to post or comment. You cannot control what others write. But you can hit Delete. And Deleting people’s comments may make them feel hurt or censored. It’s one thing when it’s your friends or family who are experiencing this. But when it’s your client, you have a clinical dilemma of your own making.

Pitfalls of Twitter
There are times when you may find yourself tempted to get caught up in passionate exchanges on Twitter on issues that are meaningful to you. The conversation can be experienced so quickly as Tweets refresh that it’s compelling to respond immediately. But it’s hard to make a strong argument and fine-tune one’s tone in 140 characters. I try to keep the focus on lively conversations but there have been times that I felt baited by provocative Tweeters. I have sat with my fingers hovering over my keyboard, trying to compose a Tweet that I’d feel comfortable with any and all of my clients finding at some point down the line. And I will admit to a handful of times that I’ve deleted Tweets when I wasn’t sure I wanted to live with them forever. This has happened when I wasn’t sure if I’d expressed myself well or when I felt a corny joke fell flat. (Note that these will still show up in RSS readers and be archived if you have posted them under a public account. There also used to be a website called Tweleted that allowed you to view Tweets that had been deleted by users with public accounts.)

As your number of Followers increases, you will have more random comments, questions, and spam directed your way. I've had to learn to resist the impulse to reply to every question or comment. It is wise to conserve your time and energy and focus on conversations that have high value to you, but being more selective may bump up against your own worries of being rude or ignoring folks.

There was a time when I felt that I should try to confine my Tweets to "normal" waking hours. I have a tendency to stay up late at night. I like the quiet hours when I do most of my inspired writing and when I’m least likely to be interrupted. Sometimes I wake up at night and I may wind up online where I’ll find an interesting psychology-related news item that I want to Tweet. For a while, I worried that clients might know too much about my habits if I posted late at night. At some point, I gave up on worrying about the timing of my Tweets and decided to allow myself to do what felt natural to my own rhythms. What a relief. Now I feel that so long as I'm fully showing up for client sessions, giving my patients my full attention, and keeping good boundaries about the content of my Tweets, when I Tweet is really my own business. But it is an interesting conflation of both personal and professional space. In a similar vein, clinicians with public Twitter accounts may want to be aware of the effect it may have on clients if you are busy updating your social media profiles before responding to a client’s phone message or email. We may be unwittingly conveying a hierarchy of priorities that can leave clients feeling less important.

Another challenge of Twitter in regard to clinical care is the need to be aware that it’s not just our own therapy clients who may follow our postings there. In some cases, others in our clients’ lives may also follow us and this may have an impact both on the client and on our clinical relationship. For example, a client may share with one of his friends, family members, or relationship partners that he sees a therapist and that his therapist is on Twitter. These people may wind up with strong opinions about our social media presence or react to things we post, and this may put our client in the position of either feeling protective of us or feeling uncomfortable. Even clients who don’t tell others who their therapist is may have such feelings if and when they see us engaging with others on social media. And what of clients who have friends who follow our updates but who don’t know their friend is in treatment with us? By making ourselves public figures in this way, we’re certainly introducing some non-traditional dynamics into the traditional therapy relationship. Of course, this potential tension has always existed with therapists who write books or are public speakers, but social media increases the ability to immediately access a therapist’s public presence.

Conclusion

Having a social media presence certainly is not for everyone. A clinician usually has to have some natural attraction to the media in order to be able to cultivate and care for their professional presence on the Internet. Also, given how visibility in the social networking world is a fairly new thing for many professionals, one also has to be prepared for some of the negative critiques one may elicit from other professionals about the effects of breaking the therapeutic frame. However, it’s important to bear in mind that we do not yet have any empirical evidence that it is harmful to clients in any way to view their therapist acting as a professional outside of the office.

I see one’s professional online identity—so long as the interactions are professional and not personal—as a form of community outreach. I have compared it to working in a college counseling center and then visiting a class that your client may be a student in, such as when a community event affects the campus and you provide information or do a presentation. Sometimes we are visible in the community as mental health professionals and clients may see us acting in this role outside of therapy sessions. An online professional presence can be similar. Some of us are teachers, writers, and lecturers, as well as clinicians. This is our professional life. Perhaps we do not have to exist in a vacuum, only functioning as clinicians in our therapy sessions. Existing online does not have to mean we cannot hold the frame with our clients, nor does it have to mean we are incapable of boundaries or talking about the effects of our online visibility on clients, when necessary. But we are going to have to develop tools and systems to learn to take care of boundaries in new ways and be present to talk with clients about the effect our online lives have on the clinical relationship.

Copyright © 2010 Psychotherapy.net. All rights reserved.
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Keely Kolmes Keely Kolmes, PsyD is a clinical psychologist in private practice in San Francisco. She writes and speaks on the intersection of clinical care and social media and provides training and consultation to other mental health professionals on these topics. She is currently researching the impact of extra-therapeutic encounters on the Internet between therapists and their clients. She will be presenting at the 2010 APA Convention this August on a panel called Social Media and Psychology—Opportunities and Challenges for Practitioners. Her C.V. and blog are available on her website She keeps a blog specifically to help psychotherapists understand and manage social media: drkkolmes.com/blog/clinicians. She can also be followed on Twitter at twitter.com/drkkolmes.

CE credits: 1

Learning Objectives:

  • Describe how therapists can use social media to augment their professional practice.
  • Identify the legal and ethical issues affecting the use of social media.
  • Identify common mistakes and pitfalls therapists may encounter when using social media.