Your therapist is on TikTok. Will your therapy session end up there too?



Published Mar 23, 2023


By Maham Javaid

Patients share their deepest fears and darkest secrets within the safe confines of a therapist’s office. And increasingly, therapists are sharing versions of those stories with millions on TikTok.

As social media plays an ever-more central role in society, therapists have taken to online spaces to discuss mental health issues. Many of them share video vignettes that re-enact conversations with clients.

As a result, more patients are being asked to sign social media consent forms that allow therapists to use behind-closed-door revelations to inspire online content.

Therapists pledge to avoid including identifying information, but still patients may find their painful breakup or troubled relationship with their parents on TherapyTok.

Therapists see their foray into social media as a way to help a wide range of people by sharing coping strategies and de-stigmatising mental illness in a society with dire mental health concerns.

But ethicists worry it could lead to therapists putting virality over patients’ best interests.

Historically, doctors and mental health professionals have been vigilant about guarding patients’ privacy, using only composite examples when sharing patient stories at conferences and in journals and books.

But TikTok is new ground, and professional guidelines are struggling to keep up with technology.

The American Psychological Association produced a set of non-binding social media guidelines in 2021, but it hasn’t addressed the issue of sharing anonymised or generalised client conversations on TikTok.

“When the writers were building the social media guidelines, I don’t think it occurred to them that a therapist might go on TikTok," said Vaile Wright, senior director of health-care innovation at the APA.

“There’s no overarching policing system out there to ensure that therapists are not violating patient privilege and confidentiality.”

Licensed mental health counsellor Jessa White said she hopes her videos will help people learn how therapy works. One popular TikTok format is “conversation pieces” – vignettes between clients and therapists that are humorous, relatable or teachable.

In one recent post, White acts out a conversation where she’s comforting a patient describing intrusive thoughts that everyone hates them.

“I wanted to be an account that makes people feel normal, comfortable, and teaches them something about therapy,” White told “The Washington Post”. She has more than 170 000 followers on TikTok and some of her videos have been viewed almost three million times.

Scores of therapists on TikTok are gravitating to content creation. Videos show patients needing reassurance after divulging their childhood trauma, joke about how therapists re-enter conversations after zoning out for a few seconds, or poke fun at the traditional idea of therapists needing to maintain boundaries from patients.

TikTok therapists say they pull video ideas from their imagination, or draw from therapy sessions after ensuring that clients have signed consent forms and aren’t identifiable.

“My conversation pieces on TikTok are so ambiguous and open that they could be about anybody,” White said.

“I have never made a TikTok based on or inspired by an actual client session,” said licensed doctoral therapist Courtney Tracy, who has 1.8 million followers on TikTok. “Unless it’s (impact) was extremely far-reaching.”

In one TikTok, Tracy portrays herself as a young therapist nervously preparing to engage with a patient who had recently tried to end their life, only to find the patient surprisingly willing to open up.

She told “The Post” she had felt ill-prepared to see the client, but since the interaction went well, she shared her story to encourage other clinicians. She said that to protect the client’s anonymity, every “demographic and clinical piece of that content was changed”.

Therapists’ code of ethics bar them from sharing information that can identify a client. Still, a client may see themselves in their therapists’ TikTok, even if the video is not about them.

“I tweet out snippets of dialogue from the session because I feel that in the therapy room, only one person benefits, but on social media everyone can learn from that conversation,” said psychotherapist and author Lori Gottlieb.

“Everybody who comes into my office knows that as long as their identity is protected, they might end up in a book or a podcast, or social media.”

Therapists pledge to avoid including identifying information, but still patients may find their painful breakup or troubled relationship with their parents on TherapyTok. Picture: Pexels Cottonbro Studio

Gottlieb said that sharing these conversations on social media helps her clients feel less alone and “democratises therapy”. As long as her clients are signing their informed consent, she said, they won't be blindsided finding their conversations on Twitter.

A number of therapists provide social media consent forms to new patients.

Tracy has a social media section in her consent form. It reads in part: “We use our social media accounts to provide psychoeducation to a larger audience and to market our practice.

“You may follow these accounts and interact with them as you’d like. However, we highly discourage commenting and stating you are a client or doing anything that could be perceived as you disclosing our therapeutic relationship.”

Her form promises that she will not follow back or interact with clients on social media and will “never disclose any identifiable information about you or your treatment and never utilise personal situations or disclosures to develop our marketing or social content”.

Young people say they are unlikely to read consent forms in detail.

“Gen Z is struggling with mental health and desperate for therapy, they aren’t really reading these consent forms,” said Maria Hernandez, a 21-year-old music business major at Bentley University.

She has been with her therapist for one and a half years and can’t definitively say whether her consent form had such a section.

If her therapist wanted to make a TikTok based on her session, Hernandez would agree, she said, if it helped others and she was specifically asked for consent.

“Therapists should only be making this content if they are receiving enthusiastic, over-the-top excited consent from clients for each of these videos,” she said. “It shouldn’t be something they ask once and use for ever.”

Some medical ethicists worry about therapists being on TikTok and don’t think consent forms provide enough security.

“If a physician on TikTok is having patients sign off to be content, they should consider leaving medicine and becoming a social media influencer instead,” said Dominic Sisti, an associate professor of medical ethics and health policy at the University of Pennsylvania.

Not all therapy TikToks are concerning for Sisti. There are some that can allow for conversation about a serious topic like an abusive relationship, by breaking the ice or adding some lightness to a heavy situation.

“My general issue with all of these is that they’re not about helping patients often,” he said. “They’re really about helping professionals, therapists, self-help people build a body of work and social media clout.”

Tracy said some early TikTok therapists started gathering informally in 2020 to discuss boundaries.

They developed broad ethical guidelines: Don’t offer direct relief in comments or direct messages; don’t break confidentiality of any kind; only provide evidence-based and peer-reviewed education unless otherwise stated; and refrain from giving direct therapeutic advice.

“There was no rule book, but we knew our responsibilities,” she said. “We frequently hold each other accountable and support the overall mission and code of ethics of each of our respective fields.”

Sisti said this form of accountability is not enough. “Potential patients, peers, other clinicians in the profession should form an independent group that can hold content creators accountable,” the medical ethicist said.

A number of health-care workers have faced professional consequences over TikToks.

Four nurses at an Atlanta hospital were disciplined and left their jobs in December amid backlash over TikTok content about their “icks” regarding new and expectant mothers.

Last summer, therapist Shabree Rawls posted a TikTok that many viewers saw as criticising the emotional intelligence of black men. After it went viral, she said she was fired from her job and faced doxing and harassment.

Florida therapist Ilene Glance faced widespread condemnation in 2021 after creating a video criticising clients who “trauma dump” in their first session. She said she lost clients due to the backlash and deleted her TikTok account amid harassment online, by phone and in the mail.

Despite those missteps, therapists and others see the benefit of TherapyTok. Conversational videos can create a sense of empathy for young viewers, said Jacqueline Vickery, research director of the University of North Texas’s Youth Media Lab.

“Young people use TikTok the way older generations use Google,” she said. “The country's mental health needs are growing, and if TikTok is where young people are searching for answers, then therapists should be there.”

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