The credit card commercial asks, "What's in your wallet?" I'd like to know, What's in your Facebook? Curious question? It's about technology, boundaries and patients.
Technology, as viewed by a technopeasant
I admit it, I am a technopeasant. If I want to know anything about my iPod, computer, Facebook account, downloading music, or anything to do with technology, who do I go to? My daughters, of course. You likely do the same if you were born before 1980. I reluctantly came into the 20th century with my email account and website, www.ichc-us.org (guess who my webmaster is, my daughter), and I burst into the 21st century now with a Facebook account. I am so proud of myself. I actually loaded my own pictures to my Facebook page.

Even as I was emerging into cyber space, I had some nagging questions. Who has access to this information? How much personal information should I put on Facebook? How confidential is this information? Although my daughter assures me that only those who I invite in as friends could get to my Facebook page, I am not fully satisfied. After all, I am of the generation that hid under our desks in school, with shades pulled down, to ward off a nuclear attack by the Soviets (naively believing that would do any good in the midst of a nuclear blast). Then, I started hearing stories about counselors sharing access to their Facebook accounts with former (and current) patients, or chatting together through the account or Instant

Messaging. Some of our organizations have websites with information about the clinicians that work there, including their academic training, places of prior employment and credentials. I have my resume on my website; perhaps you do, too. When we get into web-based patient information through software — now available through Google, Microsoft, etc. — the questions of confidentiality loom even larger. So, what’s in your Facebook, or website? Where is the line between technology and a boundary violation?

Technology and boundaries

A boundary is an edge of appropriate behavior at a given moment in a relationship between a patient and a provider, as governed by the therapeutic context and contract. A boundary crossing is a benign deviation from what is considered to be standard practice. It is determined to be harmless, non-exploitative, and may advance the goals of therapy. For example, it is winter in New England as I write this article. A nor’easter is coming. I have just seen a client and exit my office to go home. Traffic is snarled and bus services stopped due to the storm. On the street corner is a client I saw a few hours earlier, trying to get a ride home, having to walk miles to the local taxi stand. Do I pick him up and drive him to the stand, even if my code of ethics (or agency policy) might say “no?” To pick up the client might be viewed as a boundary crossing.

Echoing in my head, though, is the wisdom of Karl Menninger, a founder of psychiatry, “When in doubt, be human.”
A boundary violation is a significant deviation from standard practice. It would be seen as harmful and exploitative, taking the therapist out of his or her professional role. The key question to determine the fine line between a crossing and a violation is: “cui bono,” who benefits? Boundary issues are important because they can distort the therapeutic bond; impair the counselor’s judgment; raise conflict of interest situations; and perhaps, exploit the client.

Besides Facebook and the Internet, boundary lines include: the giving and receiving of gifts to/from clients; our mode of address (“Doctor,” “David,” “his holiness”); self-disclosure (a “biggie” in our field); contact outside the office (face-to-face or technological); touch and physical contact; and the question we so often grapple with: “How long is a client a client.” We can legislate the boundaries. For example, regarding gifts, we can place a monetary value on the gift (handmade or purchased), define it by the type/stage of treatment, type of gifts or characteristics of the patient (age or culture).

Some things are clear. Setting and maintaining the boundary is always the counselor’s responsibility and the patient should not be blamed or stigmatized for violating a boundary. Thank goodness we rarely get sued as addiction professionals; but on those rare occasions when it does happen, the number one reason for a suit is a boundary violation, typically a form of sexual impropriety. The top claim heard by state ethics boards about counselors is a form of dual relationship.

So, is it a boundary crossing or a boundary violation for a client to access your Facebook account? I find little solace in my daughter’s statement that people have to be invited in as friends to access your Facebook page because, as I have found out, anyone who has access to my email address can get to my Facebook page. Now, I still have to confirm them as “friends,” however, our clients are very skillful in getting around that “wall.” Besides, for some clients, it might present an interesting, exciting challenge to hack through that “wall.”

Let me pose some questions for supervisors to ponder. Are dual relationships (such as client’s accessing your personal information on the Internet) always synonymous with harm, exploitation or potential acting out? Are we just “burning the technological heretic at the stake” by blaming the technological advancement when the responsibility lies in the field itself to set limits? To what extent does “sterile therapy” — where no personal information is disclosed in any form — increase the counselor’s power, sense of omnipotence and client feelings of helplessness? Are some forms of technological boundary crossings therapeutically supported?

To answer these questions we must assess:

1. What’s the rationale for having the technological tool potentially available to clients?
2. What information should I post on my Facebook page?
3. What is the foreseeable impact of this information on my clients?
4. Is having this information available on the web consistent with my therapeutic contract with clients, and informed consent, on both sides?

Be leery when a clinician says, “I don’t usually do this with my patients, but in your case I will …. invite you into my Facebook account, give you my website, email address ….”  Good intentions are not enough. The impact on the client must always be the primary consideration. Even when the client initiates a boundary crossing, it is the clinician’s responsibility to “guard the gate.”

Here are some clues for supervisors when boundaries might be crossed:

• When therapy seems adrift
• When there is a difference between what is on the record and what is told to you by the counselor
• When the client seems to be overly friendly to the clinician
• When you see mistakes and slips occurring, undue special treatment provided, isolation of the client from other staff, secrets and even boredom or drowsiness when speaking of certain clients

So, what’s in your Facebook? What’s on your website? Before you all try to go to my Facebook account or website, I have to say (maybe defensively) that I gave up my private practice 10 years ago (“How long is a client a client, Powell?”). However, I must confess that I am overseeing a 60-bed adolescent substance abuse treatment center in Southern Turkey, with several very creative teenage boys who would love to crack into my Facebook account, just for the challenge of doing so; or visit my website just to learn something about this crazy American who visits them monthly. So, I am asking myself the same questions, “So, what’s in your Facebook/website, Powell?”

If you want answers in this article, sorry. I am raising the questions that the field needs to discuss and debate. And what is the role of the clinician and the supervisor in determining and monitoring the extent of personal information available to the world on the web?

Ok, so call me old fashioned, but …

Don’t get me wrong, I love my iPod, as anyone who sits next to me on an airplane can attest. (“Turn off all electrical devices, please, for take off and landing,” as if I can hear that message with my iPod blasting and my Bose Noise Cancellation Headphones). I strongly support cyber counseling (www.egetgoing.com), and especially clinical supervision done online. It will revolutionize supervision in the next decade. I am raising the questions of technology and its impact on boundary issues for clinicians, to begin the discussion that clinical supervisors, state ethics boards and counselor associations need to have. With technical advancement comes a new array of ethical and legal questions.

Gutheil, T, and Brodsky, A. Preventing Boundary Violations in Clinical Practice. New York: Guilford Press, 2008.

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