Psychiatry 75(1) Spring 2012

Addressing Therapeutic Boundaries Ginory et al.

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Addressing Therapeutic Boundaries in Social Networking

Almari Ginory, Laura Mayol Sabatier, and Spencer Eth
Facebook is the leading social networking website, with over 500 million users. Prior studies have shown an increasing number of housestaff accessing the site. While Facebook can be used to foster camaraderie, it can also create difficulties in the doctor-patient relationship, especially when boundaries are crossed. This study explored the prevalence of such boundary crossings and offers recommendations for training. An anonymous voluntary survey regarding Facebook use was distributed to current psychiatry residents through the American Psychiatric Association (APA) listserv. Of the 182 respondents, 95.7% had current Facebook profiles, and 9.7% had received friend requests from patients. In addition, 18.7% admitted to viewing patient profiles on Facebook. There is a substantial utilization of Facebook among psychiatric residents as compared with prior studies. Specific guidance regarding social media websites and the potential for ethical difficulties should be offered to trainees. The popularity of social networking has grown in the past few years, and Facebook is the leading social network site, providing an efficient on-line medium for communication with relatives, friends, and coworkers. Facebook was founded in 2004 and allows users to create a profile with personal information about their education, career, and interests, and where they can upload pictures (Facebook Factsheet, 2011). Users can then allow others to view their profile and post information on their page by adding them as friends. Facebook also lets users personalize the information that is visible to others by adjusting the privacy settings. They have the option of setting their profile to public, which means it can be seen by everyone with a profile, or private, which means it can only be seen by friends (Facebook Factsheet, 2011). According to the Facebook statistics page, there are over 500 million users, 30% of whom are within the United States (Facebook Press Room, 2011). Mobile devices also facilitate access to this network, with 200 million users accessing Facebook at any given time from a mobile device (Facebook Press Room, 2011). In a recent report from Edison Research, 51% of all Americans over the age of 12 had a profile in the social network (Webster, 2011). A study conducted at Rouen University Hospital in France of resi-

Almari Ginory, D.O., and Laura Mayol Sabatier, M.D., are affiliated with the University of Florida Department of Psychiatry. Spencer Eth, M.D., is Director of the Forensic Psychiatry Fellowship Program and Voluntary Professor of Psychiatry at the University of Miami Miller School of Medicine. Special thanks go to Dr. Patricia Recupero and Samara Harms for their valuable input and to Dr. Pedro Ruiz for his critical review of this manuscript. Address correspondence to 8491 NW 39 Ave., Gainesville, FL 32606. E-mail: almariginory@yahoo.com 2012 Guilford Publications, Inc.

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dents in several specialties found that 73% of residents had Facebook profiles and 6% had friend requests from patients, four of which the residents accepted (Moubarak, Guiot, & Benhamou, 2011). A study at the University of Florida revealed that 65.5% of multi-specialty residents having a Facebook profile had public settings (Thompson et al., 2008). Social networking has many positive aspects, including facilitating relationships between colleagues and providing a framework for self-expression (American Medical Association, 2011). However, there are potential pitfalls to social networking, which can create difficulties in maintaining a proper balance in the doctor-patient relationship that may lead to boundary issues. A boundary crossing, as defined by Gutheil, is a transient, nonexploitative deviation from the standard of care, which is minor and at times may actually be beneficial in the treatment (Gutheil, 2005). Examples include providing the patient with limited personal information, helping a patient who has fallen, or doing a home visit for a patient who is ill. A boundary violation is defined as a deviation from the standard of care that is exploitative and harmful to the patient, such as entering into a sexual relationship (Gutheil, 2005). While on a social networking site, physicians may inadvertently reveal personal information about themselves which, depending on the type of information, can be perceived as either a boundary crossing or a boundary violation (Gutheil, 2005; Gorrindo & Groves, 2008). Another aspect of boundaries is that of dual relationships, which are defined as several separate relationships with the same individual (Endacott et al., 2006). A physician may enter into a dual relationship with a patient when an online connection is established that does not directly relate to patient care (Moubarek et al., 2011; Gabbard & Nadelson, 1995). Facebook users are allowed to enter both personal and professional content. This variety of available information combined with the public nature of some profiles can

lead to negative repercussions and cause others to question the professionalism of the physician. For instance, a psychiatrist serving as a child custody expert on the West Coast was linked to lewd photographs on the web and material that promoted use of illicit drugs, unprotected intercourse, and male prostitution. The discovery of this material resulted in his removal from a custody case and placed his career in jeopardy (Christensen & Kim, 2011). In another example, a humanitarian group of medical professionals that offered care in Haiti after the earthquake of 2010 posted inappropriate Facebook pictures of Haitian patients that prompted several dismissals (Valencia, Fernandez, & Deaton, 2010). Recently, the Rhode Island State Board reprimanded an emergency medicine physician after she posted information about a patient on Facebook (Conaboy, 2011). Even though she did not post any patient data, the information posted about the injuries allowed someone in the community to identify the patient. More issues remain to be addressed, and psychiatry residents, fellows, and other mental health professionals face difficult ethical questions on a daily basis. Although the American Medical Association (AMA) issued guidelines regarding professionalism in social media, the use of Facebook among residents and fellows in the field of psychiatry remains understudied (American Medical Association, 2011). In this study, we aim to obtain preliminary information regarding psychiatry residents utilization of Facebook and potential professional and boundary violations. The secondary aim is to evaluate the amount of education residents are being provided with on these issues by their residency programs and to assess the need for improved training.
METHODS

An online questionnaire was developed using the web-based application www.

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TABLE 1. Resident Demographics (n = 182)

Gender Male Female Age 2529 3034 3539 40+ Marital Status Never Married Married Divorced/Separated Domestic Partnership/Cohabitating PGY Level PGY 1 PGY 2 PGY 3 PGY 4 Chief Resident Fellow Geographic Region Northeast Midwest South West 23.6% (43) 9.3% (17) 41.2% (75) 25.8% (47) 12.6% (23) 14.8% (27) 19.8% (36) 13.7% (25) 29.1% (53) 9.9% (18) 32.4% (59) 58.8% (107) 1.6% (3) 7.1% (13) 26.4% (48) 50.5% (92) 12.6% (23) 10.4% (19) 44.5% (81) 55.5% (101)

surveymonkey.com to assess Facebook use by psychiatry residents and fellows, and to elicit concerns housestaff may have about the social networking site. An email with a link to the survey and an explanation of the purpose of the study was distributed to psychiatry residents who were subscribers to either the Chief Resident and/or Resident listservs of the American Psychiatric Association (APA). The first page of the survey contained information regarding consent for participation. If the resident selected yes, he or she consented to participate in the study and proceeded to the next page; if the resident selected no, the survey was terminated. Participation was voluntary and anonymous. Two reminder emails were sent at seven-day intervals to both listservs to increase the response rate. Data was collected in February and March 2011. There were no incentives offered for completion of the sur-

vey. This study was approved by the University of Miami IRB for exempt status and by the APA for distribution on the listservs.
RESULTS

An email message was sent to a total of 619 residents, 310 on the Chief Residents listserv and 309 on the Residents listserv. Responses were received from 17% (53) and 41% (129) of residents, respectively, for a total of 182 residents completing the survey. Resident demographics are outlined in Table 1. A total of 89% (162) of residents who completed the survey responded yes to ever having a Facebook profile, with 95.7% (155) of those having a profile at that time. Reasons given by the few residents who had never had a profile were privacy concerns

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TABLE 2. Information Available on Profile (n = 155)

% Residency-Related Information (Program Name, PGY Status) Yes No E-mail Addresses Personal Work None Telephone Numbers Cell phone Home Work None Residency-Related Comments (Wall Posts, Status Updates) Yes No Information about Specific Patients Yes No Pictures of Patients Yes, from residency Yes, from medical mission No 0(0) 1.9(3) 98.1(152) 11.6(18) 88.4(137) 35.5(54) 64.5(98) 9.7(15) 0.6(1) 0(0) 90.3(140) 45.8(71) 7.7(12) 52.9(82) 37.4(58) 62.6 (97)

(50%) and lack of interest (50%). Of the residents with a current Facebook profile (n =155), 12.3% (19) have their account set to public, and of those with a public profile, 52.6% (10) thought it would be unacceptable behavior by the patient to access their profile. Residents were asked regarding the information that is available on their profiles as outlined on Table 2. Friend Requests A total of 9.7% (15) of residents reported having received a friend request from a current patient, with none accepting; 3.9% (6) responded that they had received a friend request from a former patient, with one person accepting and relating that they are still friends. Interestingly, none of the respondents had ever friend-requested a patient.

When asked what the appropriate response would be if a patient attempted to friend them, 85.8% (133) of residents said they would automatically ignore, while the remaining 14.2% (22) said they would discuss the request with the patient first, either in person or by message, and then ignore. Searching for Patients Next, residents were asked if they had ever looked up a patients profile on the social networking site, to which 18.7% (29) responded yes. Reasons given for searching for data about a patient included curiosity, gaining collateral or corroborating information, check up on a patient who wasnt coming to sessions, follow progress after treatment termination, and looking for evidence of [suicidal ideations]. When asked

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why the other residents had not looked up a patient, 35.7% (45) believed it to be unethical, 50.8% (64) never thought about it, and 13.5% (17) entered comments such as it seems unnecessarily invasive, and I wouldnt feel comfortable doing it. Several residents noted that such behavior could be considered a boundary crossing. Residents Concerns and Comments The final questions solicited individual concerns about Facebook and knowledge regarding social networking sites and the practice of psychiatry. Residents were asked to describe any concerns they may have regarding Facebook. Responses included privacy and confidentiality concerns, worries over their patients ability to look them up and try to friend them, potential negative effects on the therapeutic alliance if a friend request is not accepted, importance of separating professional and personal lives on such sites, concerns about how to respond to suicidal threats and other patient posts, and the possibilities for cyberstalking. Last, respondents were asked about incidents or literature regarding Facebook and the practice of psychiatry. Most were unaware of any literature and only a few (n = 5) related having discussed the use of social networking sites in their training programs. Several residents disclosed events in which staff members had been fired over their Facebook postings and of suicidal threats made by patients. One resident had a colleague who received a suicidal threat from a patient over Facebook and who then spent several hours with the police trying to locate the patient.
DISCUSSION

There are limited available data regarding Residents use of Facebook. Our survey with a small group of psychiatry housestaff that subscribed to the APA serves to provide preliminary information on issues of profes-

sionalism and boundary crossings arising due to the increased use of social networking sites, such as Facebook, and the relative lack of education provided by training programs. In an earlier study conducted by Moubarak and colleagues (2011) at Rouen University Hospital, 73% of multispecialty residents had Facebook profiles. The current study showed that 85% of the responding psychiatry residents had a Facebook profile. Both of these results show that a majority of resident are active users of the social networking site and therefore more attention needs to be placed on its importance in training and future career implications. In the same study, 6% of residents reported receiving a friend request, with 4 accepting, versus 9.7% in the current study, with no residents accepting. A total of 14.2% of responding residents reported that they would decline a friend request from a patient after discussing it with the patient, and the rest would automatically decline. Some of the responders voiced concerns about the effect that rejecting a friend invitation would have on a patient and the therapeutic alliance. Similar concerns have been voiced in previous studies (Guseh, Brendel, & Brendel, 2009). A friend request may hold similar meaning to the offer of a gift from a patient to a therapist. In that situation, it is recommended that the conscious and unconscious motivations and expectations associated with the gift be further explored (Brendel et al., 2007). Therefore, given the personal information available on Facebook profiles (relationship status, pictures, and names of friends and family) and the increased risk of boundary transgressions, it is recommended that residents should decline all friend requests from patients, accompanied by an explanation of the rationale for declining in order to minimize the effect on the doctorpatient relationship. The issue can be further explored in a subsequent session. Patients may attempt to enter into dual relationships (friend and doctor) with physicians, but it is the responsibility of the physician to es-

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tablish, explain, and maintain appropriate boundaries (Gutheil, 2005). Previous studies have shown that 5067.5% of residents have public profiles (Thompson et al., 2008; Landman, Shelton, Kauffmann, & Dattilo, 2010). The current study found that only 12.3% of respondents had public profiles. This may reflect a heightened awareness of the importance of privacy settings among psychiatry residents or may be due to a sample bias of this subgroup of residents who are involved in the APA. Residents should be aware of the privacy settings of their profile and what information is readily available to the public eye. Even though the percentage is lower in this study compared to previous studies, it is recommended that all residents maintain the highest privacy settings when utilizing social networking sites for personal use (Gabbard, Kassaw, & PerezGarcia, 2011). Facebook routinely updates their privacy settings, and residents should be cognizant of these changes and routinely monitor the site to be sure they are employing the most secure settings available. In the future, if residents have a page meant for professional usewhich they intend to leave as publicpersonal information should not be included but should instead be restricted to a secure private profile. Professionalism, defined as the commitment to carrying out professional responsibilities and an adherence to ethical principles, is crucial to the practice of medicine and is one of the core competencies articulated by the United States Accreditation Council of Graduate Medical Education (ACGME) (Accreditation Council for Graduate Medical Education Outcomes Project, 2011). There are several aspects of professionalism outlined by the ACGME, such as having respect for the privacy and autonomy of patients, which may be abrogated by residents using social networking sites to discover information about patients, as was done by 18.7% of the residents surveyed. Another aspect of professionalism is recognizing a responsibility to both the patient and the pro-

fession that is threatened when physicians post inappropriate statements about work and/or patients, or upload pictures of patients (ACGME Outcomes Project, 2011). In the survey, 35.5% of respondents had posted work-related comments as either a status update or a wall post, and 11.6% admitted posting information about a specific patient. Such postings can be considered privacy violations and can have significant negative ramifications for the residents future. As mentioned earlier, an emergency medicine physician was fired over a status update about a patient, even without mention of patient identifiers, and was reprimanded by the medical board (Conaby, 2011). Additionally, the American Medical Association (AMA) recommends that such inappropriate behavior be reported (American Medical Association, 2011). So even with privacy settings ensuring that information is not visible to patients, it may still be seen by colleagues, attending physicians, or support staff who have been added as friends. This information could then be reported as a breach of confidentiality. Therefore, it is recommended that no information about patients, even though de-identified, be posted on Facebook. If patient information is posted onto a residents profile by a colleague, it should be deleted immediately, with a communication to the colleague about the implications of that type of post. If a resident sees an unprofessional post about a patient on another residents profile, he or she should notify that resident and request that the information be deleted immediately. If the information is not removed, the training program director should be notified (American Medical Association, 2011). Both the AMA and the American Association of Directors of Psychiatry Training (AADPRT) have taken action to develop guidelines and education about professionalism and the use of social media. AADPRT recently created the Task Force on Professionalism and the Internet, which in February 2011 developed a model curriculum to

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TABLE 3. Summary of Guidelines for Maintaining Professionalism in Social Media

1. 2. 3. 4. 5. 6. 7. 8. 9. Physicians should regularly update their privacy settings. Physicians should remain aware of guidelines regarding patient confidentiality and refrain from posting identifying information about patients, including photographs. When interacting with patients online, all boundaries should be maintained based on previously set forth guidelines. Entering into dual relationships with patients should be avoided. Physicians should maintain adequate separation of personal and professional information, and on personal profile, they should be wary of the pictures and information available, as even with privacy settings items may be visible publicly. Inappropriate behavior online should be discussed with the individual, and if it remains uncorrected, it should be reported to the proper authorities. Physicians should regularly monitor their Internet presence by conducting regular web inquiries to search for information that may be publicly available. Training programs should develop policies for professional use of social media and educate residents on possible boundary crossings and violations of professionalism. Physicians should be aware that there might be negative repercussions for content posted.

(American Medical Association, 2011; Gabbard, Kassaw, & Perez-Garcia, 2011)

teach residents and students about potential issues pertaining to ethics and professionalism (American Association of Directors of Psychiatric Residency Training, 2011). Both the AMA and a recent paper by Gabbard and colleagues (2011) have formulated guidelines for online professionalism that are summarized in Table 3 (AMA, 2011; Gabbard et al., 2011). Most housestaff related not having received prior education regarding Facebook, and many voiced concerns about privacy and confidentiality issues and over the firing of others because of posts. It would seem that residency training would be the best time for physicians to learn about the pitfalls faced in social networking before starting their independent careers; yet little, if any, training is currently provided. This may be due to a lack of data regarding boundary and professional violations on Facebook. It may also arise from a lack of awareness by residency training directors who do not have as much experience with social networking as does the rising generation of physicians. More instruction during psychiatric trainingon therapeutic boundaries and the application of this concept to the Internet and social networkingwill enable residents to more effectively negotiate the complexities of the doctor-patient relationship in the era of social media (Gutheil & Brodsky, 2008). Curricula

should be updated to include periodic discussions on social networking as it pertains to therapeutic boundaries and professionalism. Residency programs should develop policies for professional use of social media and discuss them with residents (Gabbard et al., 2011). In addition, residents should be instructed on the guidelines presented in Table 3 during orientation and throughout residency. Limitations to this study include that it was conducted as a voluntary self-report, and residents may underreport aspects of their Facebook use that reflect a social desirability bias by responding in a manner that may be viewed positively by others. Also, since the survey was about Facebook, residents without profiles may have been less likely to complete the survey, resulting in an overreporting among users. In addition, there are over 5,000 residents in ACGMEaccredited psychiatry programs (American Psychiatric Association, 2010), and this survey was sent to 619 residents who subscribe to the APA listserv. As such, this is a select sample of psychiatry residents, with a response rate of only 29.4%, and may not be generalizable to the all psychiatry residents. Those who subscribe to the APA listserv may be more tech savvy and more aware of discussions of such issues. Larger scale studies need to be conducted that include residents outside the

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APA in order to be representative of the entire resident population. In summary, this survey provides firstgeneration data on the ethical and clinical implications of social networking by psychiatry residents. It also identifies the lack of

attention to these issues in residency training programs. Curricula should be updated to provide proper education to residents on the challenges faced in navigating through the social network.

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