Boundaries with Social Media: Ethical Considerations ...

Journal o f Applied Rehabilitation Counseling

Boundaries with Social Media: Ethical Considerations for Rehabilitation Professionals Ashley K. Crtalic Reg L. Gibbs Matthew E. Sprang Tom F. Dell

Abstract — The increase in social networking media, online and distance counseling, and the ubiquitous use o f laptops, hand-held devices, and internet connected devices at home and in work settings have resulted in the need fo r ethical standards to help guide rehabilitation p ro fessionals in service delivery. In response, the Commission on Rehabilitation Counselor Cer tification (CRCC) has incorporated Section J: Technology and Distance Counseling into the CRCC Code o f Ethics. Additionally, the CRCC released a social media policy on their website. However, specific ethical standards addressing the use o f social media have not been implemented. The purpose o f this manuscript is to address potential issues that can arise in interacting with clients through social media. Specifically, we will discuss the following ar eas: (1) digital immigrants and natives, (2) social media mechanics, (3) advantages o f using social media, (4) disadvantages o f using social media, (5) social media and the CRCC Code o f Ethics, (6) using social media professionally, privately, or not at all, and (7) implementing a social media policy. Discussion and recommendations are provided.

he increase in social networking media, online and distance counseling, and the ubiquitous use of laptops, hand-held devices, and internet connected devices at home and in work settings have resulted in the need for counseling professions to provide ethical standards to address privacy and security concerns (Mui, Sprong, Lee, Chowdhury, & Flowers, 2013). One such counseling organization that has developed ethical guidelines to address the potential ethical concerns of the use of technology in distance counseling is the Commission on Rehabilitation Counselor Certification (CRCC). The CRCC is a professional organization that establishes a standard of quality for rehabilitation professionals working in different avenues of service delivery (Parker & Patterson, 2012). The primary focus of this profession is to improve the subjective well-being (feeling of satisfaction with life) of persons with disabilities by addressing their vocational, medical, psychological, and social needs (Rubin & Roessler, 2008). The CRCC has established certification procedures for rehabilitation professionals (Certified Rehabilitation Counselors [CRC]) interested in “providing services w ithin the scope o f practice for rehabilitation

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professionals...while demonstrating the beliefs, attitudes, knowledge, and skills, to provide competent counseling services to work collaboratively with diverse groups of in dividuals...” (CRCC Code of Ethics, 2009, p. 1). Further more, the CRCC has developed comprehensive ethical guidelines to help facilitate effective service delivery. A current topic of interest and potential ethical concern is in teracting with clients via social media by rehabilitation pro fessionals in a world where the use of social media as a communication medium is becoming increasingly popular. According to Kaplan and Haenlein (2010), social media is “a group of Internet-based applications that ... allow the creation and exchange of User Generated Content” (p. 61), and include websites such as Facebook, Twitter, and Linkedln. These websites are experiencing much growth, as users continue to subscribe to social media platforms every day. For example, Facebook has grown to 1.39 billion monthly active users, including 890 million who used Facebook on a daily basis (Facebook Newsroom, 2015). With the increased use of technology in counseling, the CRCC Code of Ethics incorporated “Section J: Tech nology and Distance Counseling” to provide specific guide lines to help foster effective and efficient service delivery

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online. The subsections provide specific areas to consider when utilizing technology in service delivery (e.g., accessi bility, confidentiality, informed consent, distance counsel ing security and business practices). However, the current CRCC Code of Ethics does not have specific standards in Section J. that clearly address social media usage. The pur pose of this manuscript is to address potential issues that can arise in interacting with clients through social media. Spe cifically, we intend to discuss the following areas: (1) digi tal immigrants and natives, (2) social media mechanics, (3) advantages of using social media, (4) disadvantages of us ing social media, (5) social media and the CRCC Code of Ethics, (6) using social media professionally, privately, or not at all, and (7) implementing a social media policy. It is apparent that potential ethical issues with social media may impact all counseling disciplines.

Digital Immigrants & Natives While websites such as Facebook have commonly been used primarily by the traditional college-aged demo graphic, currently the most rapidly growing segment of Facebook users is women ages 55 and older (Kaplan, Wade, Conteh, & Martz, 2011). According to a Salary Report (2008) conducted by the Commission on Rehabilitation Counselor Certification, almost half of all rehabilitation professionals are age fifty or older. Thus, many current cer tified rehabilitation professionals were likely not raised in a generation that experienced interacting via social media from an early age. The future generations of certified reha bilitation professionals can be termed “digital natives”, be cause they were bom into a world where the internet and other technologies are learned along with primary language. On the other hand, the older generations of certified rehabil itation professionals can be thought of as “digital immi grants” because they were bom in a different time and now must leam the new language and culture of the digital na tives so they are better able to communicate with them (Lehavot, Barnett, & Powers, 2010). Generational differences occur not just in the per sonal use of social media, but there are also discrepancies in what constitutes ethical use of social media as a professional between different generations. Lannin and Scott (2013) re viewed research that addressed age-related differences in social media use and found discrepancies. For example, one study of doctoral psychology students found that while three out of four students used online social networking of ten to communicate with friends, most established psychol ogists did not use social networking in their practice. Furthermore, in another study, 98% of doctoral psychology students reported that they had used the internet to search for at least one client’s information over the past year, a practice that is often frowned upon and seen as an invasion of privacy by established practitioners. However, according to Smith and Skaflen (2011), between 5,000 and 25,000 online contacts take place between counselors and clients each day.

Social Media Mechanics Before deciding if and how to use social media with clients, it is important that the rehabilitation professional be fully educated and have a thorough understanding of the various mechanics of the social media site they may be us ing. Section J.l.a. of the CRCC Code of Ethics clearly states that “rehabilitation counselors are held to the same level of expected behavior and competence as defined by the Code regardless of the technology used [e.g., cellular phones, email, facsimile, video, audio, audio-visual] or its application [e.g., assessment, research, data storage]” (p. 28). Social media websites use multiple terms that may be unfamiliar to non-users. While a thorough explanation of privacy settings and mechanics of all social media networks is well beyond the scope of this article, one example of how to abide to the confidentiality of client information (J.3.a.) is presented for the social media website titled “Facebook.” Currently the largest social networking website in the world (Statistica, 2015), Facebook is a social networking website that allows its members to share pictures, information, and personal messages with one another. Each user selects his or her own privacy settings from a continuum, determining who is able to see each piece of infonnation or photo he or she posts. The least restrictive setting would be “Public”, which would mean that each photo, link, or piece of infonnation the user posts is available for anyone on Facebook to review. Many users choose the setting “friends only”. In this case, only the individuals the user has added as “friends” can see the infor mation posted. When a user adds another user as a “friend”, a request is sent to the user asking them to approve or deny the friendship request. If the request is approved, the user’s content now is accessible to the “friend.” If a user decides he or she no longer wants the “friend” to have access to the posts, the user can “un-friend” the individual. After a user is “un-friended”, the individual will no longer be able to see posts from the user. However, if they share friends, the user may still be able to see other pictures or infonnation the in dividual is “tagged in”. Being “tagged” on Facebook links content (such as a picture or “status update”) from another user to an individual’s Facebook page. Facebook also has features that make it possible for a user to be “blocked”. When a user is “blocked” from a profde, the individual can no longer see that the person interacts on Facebook. Reha bilitation professionals who choose to use social media may want to consider the potential implications and issues that could arise in the counseling relationship, should a client discover he or she has been un-friended or blocked by the counselor. It is important to note that new features are con tinuously being added, and privacy settings are often changing. It is the user’s responsibility to ensure they are staying on top of this new information in order to prevent breeches in privacy or other problems. Other social media platforms (e.g., Linkedln, Google Community, Instagram) provide similar settings to allow for certain infonnation to remain confidential. How ever, it should also be noted that the policies on what re mains confidential and what is available to the public will

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change occasionally, and the rehabilitation professional should be aware of such changes as to remain in adherence to the code of ethics (e.g., maintain confidentiality). Al though the complications in maintaining confidentiality may seem overwhelming, there are advantages of using social media in service delivery.

Advantages o f Using Social Media Choosing to use electronic correspondence as a re habilitation professional in a clinical setting has many ad vantages. Kaplan et al. (2011) asserted that electronic interactions can result in less anxiety during self-disclosure and can increase feelings of emotional safety, which may make it a particularly useful tool when working with clients who have experienced social marginalization or judgment from others. Previous research that shows that people with severe mental illness and/or disabilities are stigmatized and often discriminated against have been well-documented (e.g., Corrigan, 2002; Drehmer & Bordieri, 1985). Like wise, research also indicates that individuals who seek out counseling often feel ashamed and embarrassed, and often avoid counseling because of perceptions of public stigma and social norms (Vogel, Wade & Hackler, 2007; Vogel, Wester & Larson, 2007). For example, Paulson and Krippner (2007) stated that many veterans that are in post-secondary institutions often have difficulties adjusting to college due to significant psychological problems. More over, many veterans have difficulty expressing their diffi culties, feelings, and emotional regulation. Brown, Creel, Engel, Herrell, and Hoge (2011) asserted that stigma to wards mental health services is one of the factors that con tributes to why combat veterans do not seek counseling services. Clinical services that are offered via social media may be one way to eliminate the stigma associated with walking into a counseling office (e.g., increases the poten tial of being noticed for pursuing mental health services). With respect to clients with physical disabilities, Reamer (2013) suggested that informal contact on social media sites can be seen as “humanizing” the therapeutic relationship, and using electronic correspondence can be beneficial for clients with severe physical disabilities or for clients who live long distances from the counselor’s office. It may also be beneficial to assist clients who need assistance in a crisis situation during non-traditional office hours. Utilizing social media in a vocational rehabilitation setting also has potential benefits. For example, it can be used to assist clients in identifying jobs, to connect with cli ents, and to gather feedback. Furthermore, for clients who live in rural areas, utilization of social media is beneficial for those who have difficulty traveling long distances due to his or her disability, or have other transportation-related is sues (e.g., lack of public transportation). Within this con text, social media can be used to enable the rehabilitation professional to potentially reach more clients than they could using face-to-face interactions alone, and it provides the client with greater accessibility to the counselor. Social media use is convenient, and also has benefits from a busi ness standpoint. Whether the rehabilitation professional is

looking to promote his or her own private business, or are looking to promote their services as a whole, social media provides increased awareness of their services, and in creases traffic to professional websites. For example, reha bilitation professionals can provide links for specific services on social media platforms that can help clients lo cate specific services within his or her community they may not have been aware of. Social media can also be used to better understand clients and their wants and needs from a business perspective. For example, it can be used to gauge what types of services clients are the most interested in, and what types of settings they prefer to receive them in. Addi tionally, social media provides users an opportunity to pro mote the quality services rehabilitation professionals provide and helps build stronger and more successful busi ness relationships (CRCC, 2012). For example, rehabilita tion professionals can connect with other professionals across the country via social media to brainstorm strategies and new service approaches without ever having to leave their office or wait for a yearly conference to connect with other professionals in the field. On the other hand, the CRCC are also aware of the potential perils of using social media in VR or clinical settings. For example, the CRCC (2012) has warned “if you’re online, you’re on the record everything on the Internet is public and searchable” (p. 3).

Disadvantages of Using Social Media As the CRCC outlines in Section J, “Technology and Distance Counseling”, technology usage in counseling may have potential pitfalls. For example, technology is of ten used to store, retrieve, and analyze client information (Mui et al., 2013), and accessibility to this information may be obtained by theft (e.g., hacking software), personal and unauthorized usage of agency software and hardware, or unauthorized use/modification of agency-controlled infor mation (Calluzo & Cante, 2004; Mui et al., 2013). Further more, since communication is often delivered in a non-face-to-face format, it may be difficult to detennine if you are actually communicating with a client or if someone else is attempting to portray themselves as your client. The CRCC Section J.3.C asserts that rehabilitation professionals must utilize “encrypted and/or password-protected Internet sites and/or email communications to help ensure confiden tiality when possible...ensure confidentiality of information transmitted through the use of computers, email, facsimiles, telephones, voicemail, answer machines, or other technology” (p. 28). Another disadvantage, as is the case with all elec tronic correspondence: non-verbal communication is often lost in an online platform and may lead to conflict in the counseling relationship. For example, when transmitting information via email or another online platform, the client may become confused with the meaning behind a message. Moreover, the rehabilitation professional will not be able to observe this confusion. Likewise, the rehabilitation profes sional may portray a message and the client may perceive the meaning of the message differently than what was in tended, causing a breakdown in the natural communication

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process. Another example may include technology break down. For instance, a client’s internet connection may not be available during a major storm, power outages, or due to glitches in service through his or her internet provider. Likewise, the rehabilitation professional may be unavail able and the client may have an emergency or needs access to his or her assigned counselor. Ethical standard(s) J.lO.a. (“Technological Failure”), J.lO.b. (“Unavailability”), JlO.c. (“Crisis Contact), and J.12.b. (“Inappropriate Appli cation”) provide a description of how rehabilitation profes sionals should proceed when these issues arise. For example, rehabilitation professionals should provide an al ternative method of communication in the event that there is a technological failure, provide instructions to the client in the event the rehabilitation professional is unavailable, provide referral information in the event a crisis intervention is needed for the client, and utilize “face-to-face services when technology-assisted distance counseling serves are inappropriate” (p. 30).

Social Media and the CRCC Code of Ethics

may be valuable to consider in addition to the social media policy and Section J. Incorporating the other sections will help reduce the likelihood of engaging in unethical practice. The statement regarding the primary responsibili ties of rehabilitation professionals is provided in Standard A.I., reminding rehabilitation professional that their pri mary responsibility is to “respect the dignity and promote the welfare of clients” (CRCC Code of Ethics, p. 3). Keep ing this ethical guideline in mind, along with the A.4.a. Standard to “avoid harm”, it is important to discuss with the client the potential boundary issues that can occur when us ing social media. Perhaps the standard with the most rele vance to boundary issues that arise using social media is section A.5., “Roles and Relationships with Clients.” Ac cording to this standard, rehabilitation professionals are cautioned to avoid nonprofessional relationships to the best of one’s ability. This does not only include current clients, but also nonprofessional relationships with former clients, their romantic partners, or their immediate family mem bers. The exception to this ethical guideline to avoid these non-professional relationships is if the association is bene ficial to clients or former clients. If a non-professional rela tionship is formed, rehabilitation professionals must document this and obtain informed consent from the client. The relationship must be time limited or context specific; in other words, “free-standing friendships are prohibited.” Al though this standard doesn’t specifically address “virtual” relationships, it is reasonable to turn to it for guidance in the decision to accept or deny “friend” requests on social media sites such as Facebook. As always, it is important to keep in mind Standard(s) B. 1.b-d which require rehabilitation pro fessionals to respect client’s privacy and confidentiality and to ensure that the limitations of both are thoroughly ex plained to the client and included in the informed consent process. For example, the possibility for a breach in confi dentiality when using social media sites to communicate should be fully explored and discussed. Even if rehabilita tion professionals use Section J in combination with other standards, it will be beneficial for the CRCC Ethics Advi sory board to consider implementing specific social media standards in the next version of the code of ethics. Two examples of how the CRCC Code of Ethics Advisory Board could incorporate social media standards in the CRCC Code of Ethics include (Guided by Ethical Standards H.6.a-d. Social Media of the ACA Code of Ethics, 2014);

The issue of maintaining professional boundaries is perhaps one of the most difficult to navigate, and can lead to potential ethical dilemmas in the counseling relationship. Lannin and Scott (2013) encouraged psychologists to con sider comparing and contrasting the benefits and limitations of social media usage with providing counseling services in a rural community. This statement can also apply to rehabil itation professionals. For example, there may be potential boundary violations or issues with self-disclosure. Many professionals that work in a small-rural community will know their clients, and thus there is a greater potential for dual relationships. A similar possibility occurs when reha bilitation professionals consider using social media with clients. Therefore, extra caution should be utilized when considering whether to become associated via social net working websites. It is essential that the rehabilitation pro fessional remember his or her roles, functions, scope of practice, and ethical guidelines when using social media with clients. Section J. (Technology and Distance Counseling) provides a general framework regarding technology and distance counseling. However, instructions and ethical standards that involve the use of social media (e.g., Facebook, Linkedln, and Google Community) are not spe cifically stated. For example, Section J. does not provide • Standard J.16.a. Professional Boundaries in Social details regarding communication through social network Media. Rehabilitation counselors provide information ing platforms such as Facebook. However, there is general about their use of social media in the counseling relation guidance in the CRCC Code of Ethics that can be applicable ship and discuss how social media will be incorporated. Such areas include: (1) how will the use of social media be to counselors who are struggling with ethically using social beneficial to the counseling relationship, (2) how will per media. While the CRCC has posted a “Social Media Pol sonal and professional social media platforms be utilized in icy” (2012) on their webpage, it still does not address relation to the counseling process, and (3) how tennination boundary and relationship issues in using social media with of services will impact networking on social media plat clients. Furthermore, it does not provide clear instructions forms. on appropriate ethical procedures. Since specific social me dia standards are not explicitly stated in the CRCC Code of Ethics, we believe that other sections of the Code of Ethics • Standard J.16.b. Confidentiality and Social Media. Re habilitation counselors who incorporate social media

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within their service delivery will provide individuals receiving services information related to confidenti ality. Such areas include: (1) security-related infor mation regarding how personal and demographic information will be stored and protected, (2) who will have access to this data, (3) precautions the counselor will take in preventing disclosure of confidential in formation, and (4) examples of information that is deemed appropriate and inappropriate for social media. Although such standards are not currently available to reha bilitation professionals, it is important that rehabilitation professionals understand how using social media will im pact service delivery and benefit consumers.

Using Social Media Professionally, Privately, Or Not At All The rehabilitation professional may choose to use social media professionally, electing to engage clients in the social media process; they may choose to use it privately, not intending any interaction with clients; or they may choose not to use any social media at all. These choices may have ethical implications based on counseling guidelines previously discussed. Although many counselors may use social media in their personal lives, and may not feel it is an appropriate format to use with clients, it cannot be guaran teed that social media issues will not arise in the counseling relationship. For example, a client may easily search for his or her counselor’s personal page on social media sites and request to have a relationship with the counselor. At this point, w'hether the counselor wanted to or not, he or she will now be forced to address the social media issue with his or her client. It is perhaps naive to think that the rehabilitation professional will be able to keep his or her social media use completely private and never have it enter the counseling relationship. Because the use of social media is becoming more common, it is increasingly likely that clients will search for their counselor on social media sites. Therefore, it is important for rehabilitation professionals to be knowl edgeable about privacy settings of their social media ac counts, as information the counselor shares with friends and believes to be private may in fact be available to the public and to his or her clients. With so many potential ethical dilemmas surround ing the use of social media, rehabilitation counselors might believe “shunning” the use of social media in order to avoid these ethical dilemmas is the only route to take. However, is this point of view realistic for all rehabilitation counselors? Should we expect counselors, in general, to not engage in personal social media use just because of their chosen pro fession? In an increasingly digital world it may be unrealis tic to assume that all rehabilitation professionals renounce social media even for private use in order to avoid potential ethical issues with clients. Furthermore, an argument could be made that purposely choosing to ignore social media may not be in the best interest of certain clients. Ultimately, the question rehabilitation professionals need to consider is,

what is in the best interest of the client in regards to social media use with his or her counselor? If a rehabilitation professional decides to use social media with clients, perhaps he or she could utilize the American Counselor Association’s (ACA) Code of Ethics (2014) as a guide of how to conduct oneself professionally. The ACA has incorporated Section H.6., “Social Media”, which includes four sub-standards that specifically address the use of social media. The ACA has stated in Standard H.6.a. (“Virtual Professional Presence”) that counselors who wish to use social media both personally and profes sionally create “separate professional and personal web pages and profiles” in order to “clearly distinguish between the two kinds of virtual presence.” (p. 18). Standard(s) H.6.b. (“Social Media as a Part of Infonned Consent”), H.6.c. (“Client Virtual Presence”), and H.6.d. (“Use of Pub lic Social Media”) provide additional details of how social media should be utilized and incorporated in the counseling relationship. However, to avoid being involved in an ethical dilemma, perhaps the best practice for rehabilitation profes sionals is to prevent them in the first place. In the opinion of Kaplan et al. (2011), “85% of all ethical dilemmas can be avoided with thorough and complete informed consent pro cedures” (p. 7). When working with clients who use social media, it is extremely important to educate clients about the lack of privacy of social media and infonnation posted on line, even when appropriately using privacy settings. Equally important is the potential permanency of informa tion posted on the internet. To illustrate this point, take for example a photo posted to a rehabilitation professional’s personal social media page. The rehabilitation professional has the privacy level for this photo set as “friends only” which means only people whom they are friends with are able to see the photo. After a few minutes the rehabilitation professional determines the photo may not be appropriate and decides to delete it permanently from his or her profile. However, while the photo was up, one of their online friends saved it to their computer or cell phone and now they are able to post it whenever and wherever they choose.

Social Media Policy A thorough social media policy included as a part of the counselor’s informed consent is perhaps the best way to address potential boundary issues before they arise. Even if a counselor decides against using social media with cli ents, it may be wise to include a social media policy stating this fact. One example of how to address social media with clients is by providing a social media policy that is reviewed by the rehabilitation professional and the client during the initial meeting. Kolmes (2010) stated that a social media policy should include statements on whether or not the counselor will accept friend requests, and whether or not text messages or Facebook messages can be used to interact with the counselor. Reviewing Kolmes’ policy is a good place for rehabilitation professionals to start when they be gin to craft their own version. In addition, it is important that if the rehabilitation professional does choose to use so-

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cial media, that the content is Health Insurance Portability and Accountability Act (HIPAA) compliant and does not contain session related disclosures or treatment informa tion, and that the client provides written permission to inter act informally via Facebook, text messages, etc. (Kaplan et al., 2011). HIPPA is a law that protects confidentiality and security of healthcare infonnation. As Kaplan and col leagues state, the informed consent should address confi dentiality-related issues with regards to the use of social media. Likewise, they recommend exchanging a confiden tial password prior to using online interfaces in order for the rehabilitation professional to confirm they are talking to the “real” client. Additionally, the infonned consent might also ad dress whether or not the rehabilitation professional will ac cept friend requests from clients, and if they will accept friend requests in the future (for example, once the counsel ing relationship is terminated). Also, the rehabilitation pro fessional might include a plan and policy for denying friend requests or for “un-friending” clients if necessary. Ethi cally, the rehabilitation professional may need to be aware of the implications for the counseling relationship if he or she chooses to either accept or deny a friend request, and should be prepared to discuss this issue with clients. Poten tial issues include a client feeling rejected or disliked by their counselor if the counselor chooses to deny a friend re quest. On the other hand, a client may believe the rehabilita tion professional is now more of a friend than a professional if he or she has access to the counselor’s personal social me dia page. Such a perception may limit the effects of the counseling process because the client may not take the reha bilitation professional seriously. Clients need to be in formed of the potential break in confidentiality that can occur simply from “friending” their rehabilitation professional, because of their presence on the counselor’s friend list which can be available to the public It is important to determine if and when to use so cial media personally versus professionally. For example, the rehabilitation professional needs to decide if he or she will have both a professional and a personal Facebook page. If the rehabilitation professional decides to have both, how will he or she address clients who attempt to use the per sonal page when interacting with the counselor? If the counselor chooses only to have a personal page, how will he or she address clients who attempt to use it to contact them? The rehabilitation professional also needs to define how soon he or she can be expected to respond to the client via social media. Will the rehabilitation professional be available twenty-four hours per day, seven days per week? Will he or she only be available Monday through Friday from 8 a.m. to 5 p.m.? Can the client use social media to contact the rehabilitation professional in crisis situations? This issue may need to be re-visited throughout the counsel ing relationship as well, as a client can become used to the instant nature of interacting on social media and expect that the rehabilitation professional will respond more quickly than is realistic.

Conclusion Social media use by rehabilitation professionals may still be considered a new frontier. Existing within this domain are opportunities to serve more clients and to do so more effectively. However, social media use also increases the possibilities of ethical dilemmas, particularly concern ing boundary-related issues. Because the current code of ethics does not specifically address the intricacies and spe cific dilemmas inherent in social media use, rehabilitation professionals must navigate these issues with guidance from Section J (Technology and Distance Counseling) and other applicable sections of the current code. However, even without a current consensus on what constitutes “best practice” for using social media, each rehabilitation profes sional must take responsibility for his or her current social media practices, keeping the best interests of the client first and foremost.

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