With the rising movement of e-patients and social networking sites like Facebook, LinkedIn and Myspace, a question has recently surfaced on a mental health mailing list I subscribe to where a professional asks, “When should I accept a ‘friend’ request from a patient or former patient?”

It’s a good question and one that sheds some light on the blurring of the traditionally clear boundaries between doctor and patient (or, in the case of psychotherapy, therapist and client).

It helps first to understand some terminology. A “friend request” is not exactly what it sounds like. “Friends” on social networks like Myspace or Facebook are not the same thing as when we typically think of as friends. In a savvy marketing move, Myspace popularized the terminology to describe any contact — be it a stranger, spammer, friend, enemy, family member or lover — who asks to allow them to add you to their list (or “address book,” using old-school terminology). Because Myspace makes no differentiation as to what a “friend” actually constitutes, these people are more accurately described as contacts (a term which is decidedly far less marketing-friendly). So if someone has 10,000 Myspace “friends,” that really means next to nothing, since nothing is qualified.

When you get a friend request on a Myspace or Facebook, what you’re really getting is a simple request to form a network connection between your profile and his or her profile. This connection implies some sort of two-way relationship, but often says little about what that relationship actually is (some social networking websites such as Facebook and LinkedIn do a better job of helping us identify the type and closeness of these relationships). Other people on both your network of “friends” as well as their network can see this connection.

What’s a Professional To Do?

When a psychotherapist or psychologist receives a friend request from a colleague, they typically accept it if they know (or know of) the person. But when they receive a similar request from a client or former client, many are left scratching their heads. What to do? The same is true when they receive an email from a client or former client. If the professional hasn’t set clear guidelines or expectations up-front, then it leaves the door open to such questions.

The key, then, is to clearly define the boundaries of the relationship, not only offline, but online too. This means putting together an “Internet & Email Policy” that you hand to clients during their first session and have them read and understand it. A part of that policy describes whether you accept patient email, and if so, under what circumstances (e.g., appointment changes? therapy issues?).

But a part of what should be included in a therapist online policy is what a lot of therapists miss — what to do about social networks. A friend request isn’t an email, so it’s not really covered by such things. The answer is to specifically address social networks and “friend requests” with an update to your online policy.

Consistency is important to clear boundaries in a professional therapeutic relationship. If a therapist makes an exception for a client in one circumstance, the client may unfortunately interpret that differently than the therapist intended. Clients are not a professional’s “friend” (although a friendship may develop over time) and while a professional relationship does exist amongst the two, it may not be a relationship a client or therapist is comfortable publicizing via a public social networking website.

The publication of such information, whether a client realizes it or not, may result in a violation of the client’s mental health care privacy. While they may think such a “friend connection” on a social network is harmless fun, it may be used by future employers (or even significant others!) to pass judgment or draw conclusions from that are detrimental to the client. Worse yet, the client may never know or realize that such information may be harming them (since social networks don’t tell you who’s viewed what information of yours once you make someone a “friend;” in some cases, you may not even need to be a person’s “friend” in order to view such information).

The Safest Approach — For Now

For now it’s probably best to keep the therapist/client boundaries clear and consistent online: clients should not send social networking “friend requests” to professionals, and professionals should avoid accepting them (nor send out such requests to their clients or former clients). This policy should be made clear to a new client at the initiation of psychotherapy, to minimize future misunderstanding.

Social networking is a powerful tool, but it’s also a tool that can be misused and sometimes even abused. People are not always clear or aware of what information is available to the public or their “friends” list, and what information is private. And people may not always understand the longer term ramifications and implications of sharing such information with others.

Dr. John Grohol is the CEO and founder of Psych Central. He is an author, researcher and expert in mental health online, and has been writing about online behavior, mental health and psychology issues -- as well as the intersection of technology and human behavior -- since 1992. Dr. Grohol sits on the editorial board of the journal Cyberpsychology, Behavior and Social Networking and is a founding board member and treasurer of the Society for Participatory Medicine.

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    Last reviewed: By John M. Grohol, Psy.D. on 15 May 2008
    Published on PsychCentral.com. All rights reserved.