About a year ago Cathy Malchiodi wrote an excellent article on the subject, and the comments on her blog helped to further the debate. I also discussed my opinions on the matter in a series of posts that can be viewed here, here, here and here.

One of the main points in my analysis: AATA’s ethical codes are determined by what the majority of art therapists who are AATA members think is ethical. So, fellow art therapists, fill out the survey! Even if you feel you don’t have an opinion or a good understanding of the subject—that’s all information for the ethics committee to process, and hopefully provide more education about.

Lastly, ex-AATA president, Pegg Dunn Snow, informed me that the ethics commitee would be meeting during the 2009 conference to discuss the ethical considerations of art therapy and technology—essentially addressing her example of “what not to do” when you’re advertising your art therapy practice. The advice given by the AATA ethics committee parallels my analysis, and hopefully will serve as a compass until more specific guidelines are provided.

Carly Sullens asks,

I am wondering about art therapists who are also artists who sell their work. What do we need to be aware of as clinicians when clients or interested or even buy our work?

This question generated a lively discussion about art therapist, their artwork and ethics.

As you may have noticed I have an artwork page on my blog. This is my response to the Carly’s question, although my focus is not on clients buying my artwork, but rather, seeing my artwork as a part of this blog:

I write a blog and have an artwork section, where I posted several personal pieces relating to my personal identity and struggle—mainly having to do with health related issues.

When I was studying art therapy, the program I attended emphasized psychodynamic theory, in which the blank slate was very much encouraged. As I began practicing art therapy, however, I found myself naturally gravitating more towards the humanistic side. I wondered whether, if I was the client, would I be able to relate and be open with someone who was never somewhat open with me about their perspectives and struggles? Also, because I’m young, which some people interpret as having minimal life experience, I find it important (at times) to reveal a small part of who I am in order to gain trust and encourage a therapeutic connection. That being said, I don’t advertize my blog to the clients I work with, and none have mentioned my writing or artwork to me. Similar to what others have said, if my clients asked about my artwork, I would process this, just as I would process anything else they brought into the session.

Another reason I made an artwork page on my blog is that I wanted to show other art therapists a piece of who I am, hopefully making a connection to my readers. I realize that some people who look at my blog are also prospective students or people who are interested in seeing an art therapist for their own therapy. The artwork page, along with my writing, may help to demystify what art therapy is without showing the artwork of the clients I work with, which is another huge ethical grey area—one that is worthy of it’s own discussion.

If down the road it seems that my ethical judgment was unfounded, it would certainly be a learning experience and something to be shared with other art therapists. In this world of technology and social networking the concept of privacy is changing, and so is the idea of separating personal and professional lives. Everyone with an internet presence now lives in a “small town”, since everyone can access multiple dimensions of everyone else’s lives with the click of a mouse (or, if you have an iPad, a press of the finger).

We may not be able to foresee all the pros and cons of this topic until years down the road, when more learning/experience has developed. However, the first step towards a deeper understanding of this question lies with these types of discussions. Thank you Carly!

This information was found on the Department of Health and Human Services Website:

Protected Health Information: The Privacy Rule protects all “individually identifiable health information” held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. The Privacy Rule calls this information “protected health information (PHI).”

“Individually identifiable health information” is information, including demographic data, that relates to: the individual’s past, present or future physical or mental health or condition, the provision of health care to the individual, or the past, present, or future payment for the provision of health care to the individual, and that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual. Individually identifiable health information includes many common identifiers (e.g., name, address, birth date, Social Security Number).

You cannot use any information that links an individual to their specific health information. If you post a video or pictures of a person in a way that makes it clear that they are a part of, for example, an autism group or receives psychotherapy from a practitioner who specializes in eating disorders, it allows others to put 2+2 together. The person in the picture has autism because he attends an autism group. The person in the video has an eating disorder because she receives treatment from an ED specialist.

However, also found on the Department of Health and Human Services Website:

A covered entity may not use or disclose protected health information, except either: (1) as the Privacy Rule permits or requires; or (2) as the individual who is the subject of the information (or the individual’s personal representative) authorizes in writing.

So…if you have written consent to posting that picture or video it’s okay…or is it?

Again, from the Department of Health and Human Services Website:

Minimum Necessary. A central aspect of the Privacy Rule is the principle of “minimum necessary” use and disclosure. A covered entity must make reasonable efforts to use, disclose, and request only the minimum amount of protected health information needed to accomplish the intended purpose of the use, disclosure, or request.

Is putting a picture or a video online where one can see and clearly identify the client the minimally necessary way of getting one’s point across? Not to me. The pictures could contain someone making artwork, but is shot in such a way that you can’t see their face. Efforts could be made to conceal the face of people in the video.

Let’s move onto AATA’s code of ethics.

Under the Preamble section, the AATA code of ethics states,

In this Ethics Document, the term reasonable means the prevailing professional judgment of art therapists engaged in similar activities in similar circumstances, given the knowledge the art therapist had or should have had at the time.

As a group, what we do and where our values lie helps to determine reasonable ethical judgment.

Under Client Artwork, 4.2-4.6,

Art therapists obtain written informed consent from the client or, where applicable, a legal guardian in order to keep client artwork, copies, slides, or photographs of artwork, for educational, research, or assessment purposes.

Art therapists do not make or permit any public use or reproduction of client art therapy sessions, including dialogue and artwork, without written consent of the client.

Art therapists obtain written informed consent from the client or, where applicable, a legal guardian before photographing clients’ artwork or video taping, audio recording, otherwise duplicating, or permitting third-party observation of art therapy sessions.

Art therapists use clinical materials in teaching, writing, and public presentations if written authorization has been previously obtained from the clients. Reasonable steps are taken to protect client identity and to disguise any part of the artwork or video tape that reveals client identity.

Art therapists obtain written, informed consent from the client before displaying client art in any public place.

Confidentiality, section 2.2,

Art therapists inform clients of the limitations of confidentiality.

When it comes to the internet, my opinion is that clients must be informed of where their information will be posted, what will be posted— will their face be shown? Will measures be taken to hide their identity? How secure is the website you’re posting the information on? Is the website intended for professional purposes, advertizing purposes, social networking purposes? How long the information will be available online? (Answer: all information posted on the internet is currently accessible forever).

Art Therapy by Electronic Means, sections 14.1-14.3,

Art therapy by electronic means is a new and evolving application of art therapy. As such, it presents opportunities for service, as well as ethical dilemmas not encountered in the past. Art therapists are advised to use caution as the ethical ramifications of providing art therapy services via the Internet and other electronic means emerge.

Art therapists who offer services or information via electronic transmission inform clients of the risks to privacy and the limits of confidentiality.

Art therapists who provide services through electronic means are governed by the AATA Ethical Principles for Art Therapists.

Art therapists are responsible for taking reasonable steps to ensure that any services through electronic means are in accordance with all applicable laws and regulations and are aware of the licensing requirements of the states in which their clients reside.

Under Responsibility to Clients, section 1.5

Art therapists recognize their influential position with respect to clients, and they do not exploit the trust and dependency of clients.

Although this quote was taken from the subsection discussing multiple relationships, this quote is applicable across all circumstances. When asking for consent, one cannot forget the position of authority they’re in, the tranferential relationship and the client’s (or their families, in the case of a minor) wish to please the therapist. This is where our judgment comes in. Are we exploiting the trust of clients when asking them to sign a consent form to post their faces and essentially their diagnosis on the largest social networking site to date? Not to mention that the post will also be easily accessible though Google. How about when we add to the mix the purpose of advertising or educating others about our profession?

I say yes to both questions. Others may say no. Some may not feel strongly one way or the other. Either way, I want to hear your opinions!!!

The following is my email to Dr. Dunn Snow, dated August 18, 2009:

Hi Dr. Duun-Snow,

My name is Elizabeth Beck. I’m an active member of the online art therapy community. I recently came across an article by Cathy Malchiodi on her Psychology Today Blog:

http://www.psychologytoday.com/blog/the-healing-arts/200907/facebook-fan-page-your-private-practice

Although your name is never mentioned in her article, after doing an online search it’s clear to me that Cathy is referring to your fan page for Children’s Corner: Art Therapy for Children. I write a blog myself, which can be found at http://www.lizbeck.net

I was wondering if you have a response to the article and comments made on both Cathy and my blog? I think many art therapists would benefit from clarifying your methodology in assessing the ethics of posting videos on your fan page. This truly is a new frontier and your guidance is most appreciated.

Also, I’m giving a workshop at the AATA conference in November on the topics of blogging and podcasting. Would I be able to use your response for teaching purposes in my workshop? With your permission I would also like to post your response on my blog as well.

Thank you for your consideration,
Elizabeth Beck

Dr. Dunn Snow did respond to my email, but has not given a “yes” or “no” response as to whether I can post her comments. This is only a summary of her response, rather than a direct quote:

I was hoping for a more in depth response to all of our questions, comments and thoughts. I also hope that our reactions were taken to heart by Dr. Dunn Snow. I haven’t checked her fan page in a while, but I would expect that some changes would be made, for example putting a disclaimer regarding informed consent along with the videos.

I was taken aback when I read about the art therapist who posted artwork and video footage of a client’s session (a minor) on their fan page.

My initial reaction to reading Cathy’s article is; yes, posting unedited 1:1 artx sessions of a minor, with consent, is pushing the ethics of our profession out of my comfort zone. After doing a search in facebook to find the fan page (not hard to do if you’re willing to invest a little time), this feeling was only highlighted. Admittedly I only watched the first 2 videos, but each time I heard the therapist ask the child to “look at the camera” I felt the session’s integrity was compromised. That being said, I’m also happy this happened and that Cathy wrote about it so that a dialogue can be opened within the (art) therapy community.

I have been very cautious about protecting the rights of the clients I work with, especially when it comes to this blog. I do write tidbits regarding artx directives I’ve implemented successfully, but I have never once included the artwork of the clients on this blog despite the fact that many have consented to allow their artwork to be published through any media source (i.e., film, print, computer image). The reason I have not included their artwork, which would no doubt add to the comprehension of the directive written about in the post, is that I just plain don’t feel comfortable with it. However, I intend to write either a journal article or present at a future AATA conference featuring those same directives and art pieces. Why am I comfortable accepting the consent of the clients I work with for print or lecture publishing but not for electronic publishing?

Perhaps it has something to do with accessibility. Anyone can google a facebook fan page or some key words and be directed towards, for example my blog and the potential artx images discussed above. Not everyone, however, would take the time to become an AATA member and gain access to its journal, go to a University library searching for an article or attend a conference. I’m operating under the assumption that the people who are taking interest in the artwork and directives are art therapists or other help professionals who are seeking training in art therapy, not just the random person stringing several words together in their search bar.

Another thought: Judith Rubin has made some fabulous videos that include children creating artwork during art therapy sessions. If her video were aired on PBS (maybe it already has?) or if it were posted on her web page for all to access, would I feel an ethical violation took place? Certainly not. Then why am I so uncomfortable with videos and artwork being posted on facebook fan pages?