A is for anonymity – NHS professionals online

A is for anonymity – NHS professionals online

Online personal identities will be a key theme of my virtual ethnography. I’m curious about the names, avatars and biographies we choose to have online, particularly for people using social media to engage with others on the topic of mental distress in a personal and/or professional capacity.

Qian and Scott (2007) explore the affordances and risks of blogging in relation to the subjective self. Their research suggests that sharing personal thoughts and experiences in the virtual public domain carries risks, with possible real-life costs, and as a result anonymous identities and pseudonyms are common place.  The mental health literature clearly shows that online anonymity for highly stigmatised conditions is one of the primary benefits identified by people who have lived experience. Schrank et al have identified that people use the internet for health-related information as it affords anonymity and egalitarianism (2012). In addition to anonymity, Powell & Clarke (2006 & 2007) also found that people using the internet for mental health information value its possibilities for providing privacy, convenience and accessibility.

I have found quite a bit of research literature related to people using the web in relation to their personal experience of mental health difficulties but far less about people who are working within statutory services (however, there are quite a few blog posts on the subject). This is still a tricky area for many, with much of the professional guidance focusing on avoiding negative consequences and less on the potential benefits. I have chosen to use my real name and avatar. It didn’t really occur for me to do otherwise at the time. It does mean I have to regularly exercise self-restraint, but that’s not that different to my offline life, where I make judgements all the time about what I share with whom both personally and professionally (I even occasionally get it right…).  I’ve spoken to many different people who all have their own lines in the sand about how they present themselves online. Some never tweet after a glass of wine and others never share anything in relation to their personal lives. I personally prefer a mix of professional and personal (just like I do at work and at home) but for others this can be really annoying. For some, the potential consequences of a negative reaction from an unsupportive employer, is too great for people to risk sharing their real life identity.

So online anonymity affords freedom of expression without identification and minimises the possibility of unwanted repercussions.  But does it compromise trust or believability? Does it make any difference to if/how you engage with someone if they are using an anonymous avatar? And if you are using an anonymous identity online, do you worry about consequences of others finding out your real identity?


Powell, J. & Clarke, A. (2007) Investigating Internet Use by Mental Health Service Users: Interview Study MEDINFO 2007 K. Kuhn et al. (Eds) IOS Press

Powell J. & Clarke, A. (2006)  Information in mental health: qualitative study of mental health service users Journal compilation  Blackwell Publishing Ltd

 Qian, H. & Scott, C. (2007) Anonymity and Self-Disclosure on Weblogs Available at: http://jcmc.indiana.edu/vol12/issue4/qian.html

 Schrank, B. Sibitz, I. Under, A. & Amering, M.  (2010) How Patients with Schizophrenia use the Internet: Qualitative Study Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3057320/

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  1. Hello!

    I’d love to talk more to you about this so will be really interested in the replies to this post. Are MH professionals who choose to be pseudonymous only concerned about employer’s reactions? What about ‘boundaries’ with clients? Doesn’t revealing personal details make these boundaries a little more blurred? Or are these boundaries in some way old-fashioned and dated? It’s interesting that you don’t seem to consider them an issue.

    • Thanks for your comments. I’m not sure what the answer is to your question so I’m very much hoping some mental health professionals give us their views as well as people using mental health services. Anonymity is one way to keep that boundary very clear but I wonder to what extent people who use pseudonyms worry about their real identity being revealed. I think I would find this inhibiting in an equal but different way to using my real identity online.

      • Yes, I wouldn’t like to use a pseudonym and have no real desire to reveal very much about my personal life online. I like my privacy:)

  2. Thank you, I found this a very interesting and thought-provoking article.

    I also find personal identity and anonymity online very interesting and think that there may be a role to play for professional regulators in this area. A professional regulators’ primary focus should be to protect the public and as such should aim to support professionals with guidance on how to effectively maintain a safe online presence.

    One risk of remaining anonymous online is that those who are engaged / receive a ‘service’ do not know whether they are doing so with a registered professional or not and have limited avenue for recourse to regulators should they wish to pursue any issue with practise.

    There are undoubtedly benefits to individuals who are sharing their own life experiences of remaining anonymous, but for me, the jury is still out in terms of professionals and their identity online.

    • thank you for your comment David – hadn’t thought of it from that angle so a really interesting response. I’m not convinced it is either desirable or possible to regulate in the way you describe but I’m sure there will be people out there thinking about it. I guess there is a difference to having a professional identity online and actually giving medical/clinical advice online. I’d love to hear what others think

      • Yes, difficult to regulate for. I am also aware of some professionals in particular groups who choose to use a pseudonym due to the stance that their regulator has (or rather hasn’t) taken on social media. There is a need for some regulators to be more progressive.

  3. I understand why some prefer to be anonymous. I prefer to be up front.

    Actually I’m much less inclined to trust anonymous profiles (at least at first) than those who are prepared to stand up & be counted. Deceitful psuedonyms are even less likely to earn my trust.

    I know of one contact who has had at least 3 different profiles, each with different first and family names. I will not trust this person at all.

    • thank you for your comments Stuart. I’ve never thought about not trusting people who use pseudonyms on Twitter – I usually feel a bit jealous that mine is just straight down the line and theirs is creative and/or fun. However, I think the idea of different profiles which clearly aren’t honest are a different matter I think. I tend to take tweeps at face value as I see so much good will and loveliness online so a note of caution is a good idea…

      • It’s my stereotypical Northern nature. …..

        “Say what you mean and mean what you bloody well say!”

    • I think people should be up front also, I would be interested to know what the worry is. I’m not a Proffessional but a Servive User, but I consider myself to be an expert in my field of BPD , I train CMHT staff. I do get people contacting who want to become my friend, but I think it’s easy to boundary those attempts in a lovely kind way.
      People on here do have several accounts and like Stuart I am very wary of them. That makes me wonder what their intention is, I know one person I believe to be very suspect. That makes me worry for vulnerable young people.
      I also am reminded of the recent case of the fake police guy who was recently found out. He tweeted about the riots but in truth he was a serial con man.
      We could have fake Proffessionals on here, who knows?

      • You’re a fantastic role model Sue and hold the connection between both professional and personal experience fantastically 🙂

  4. Hey Victoria, great article and very thought provoking. As a health professional who has just started twittering in my own name I thought the following may be of interest to you:
    I have been on FB and kept a personal blog for the last 7 years. In the past I have been very cautious about mixing my work / social identity – particularly with my blog.
    The first reason for this is because when I trained in OT ten years ago professional boundaries were drilled in to us so much that you left the OT course not even wanting to disclose which city you lived in, never mind any thing else. I quickly realised that the use of narrative and self can be very beneficial in building trust and rapport with clients but remained very cautious about disclosing too much personal information. I would however not feel too worried by a client stumbling across my blog as much as a colleague!!
    I think this is because when you work for a very large organisation such as the NHS you are thrown into a huge melting pot of people, this inevitably leads to cliques / politics and I have found it very useful to remain fairly neutral in my personal opinions at work in order to gain staff trust and to work diplomatically. I would be concerned that my personal blog would be judged unfairly and work against me in my role as a team leader where I need to bring people together. (However reading the comments / your article I am wondering if being more open would be an even stronger way forward?)
    I often compare the world I work in to my best friend Charlie who runs her own social enterprise (@creatingspace4u) . Charlie runs a company that is very true to her values meaning that she networks with like minded people and often blurs the roles between work / friendships in ways which I wouldn’t. Charlie isn’t accountable to anyone and sometimes can’t believe the systems in which I work. I think the NHS is a huge mix of people / personalities which in one sense makes it a really exciting environment but also makes you more cautious about the ways in which you work with your team. (Maybe this applies to all large companies?)
    I think that the culture is changing, particularly as people are becoming more familiar with computers / digital media, in the past there has been a huge amount of suspicion around technology. I think that the NHS has taken a long time to catch on – hence adding an air of uncertainty to health professionals who are worried about putting a foot out of line, so people find it more comfortable to comment anonymously than risk making an error of judgement that could impact on them negatively at work.
    Interestingly it has been really refreshing twittering in my own name disclosing my identity and my profession. Participating in twitter I have had conversations with people I see on a day to day basis in my local community who I wouldn’t have normally spoken about work to – thus helping to reduce the stigma around mental health and also widen my networks. Having said that I think it would be useful to have a separate twitter account for the CRT so that I can push the promotion of our work further and keep us on the radar of other MH organisations in a stronger way, although I would now continue to tweep personally using my original account as well.
    Even responding to this post feels like a brave step forward, although you will notice I haven’t added my blog!! Maybe next time I’ll include that too 🙂
    Regards Emma

    • Hi Emma. Thank you so much for taking a leap and responding. I think it’s different for everyone but I’ve definitely grown more confident (or others might say become more disinhibited…) in blending who I am in my personal life and who I am in my professional life on Twitter. I personally think it can be good to bring those two things together both offline and online if it feels right to you as an individual. I think a service/project Twitter account would be great and let’s discuss when we meet up. My long term dream is to have our corporate/organisational account, followed by project/service accounts and then individual accounts as well so we can spread digital engagement across our Trust from many different perspectives and engage with people dynamically in lots of different ways. Finding allies and enthusiasts in an organisation, particularly a large on like ours, is going to be pivotal in getting some good traction going. Thank you again and looking forward to discussing more in person and on Twitter 🙂

  5. Thanks for the thoughts and interesting discussion. I often consider my position as someone who identifies as a ‘professional’ (not sure I always like the self-referential nature that assumes authority in that word) and yet uses a pseudonym/anonymous profile to do so.
    I fully respect and understand that part of the issue will be concerns raised about my authenticity and am very happy for people to remain sceptical until they feel that my words/conduct prove the point – however, if people don’t believe I’m who I say I am, well, that isn’t something that bothers me particularly.
    I’d much much rather be doubted than think that someone wholly trusts without question that we are who we say we are on Twitter!

    My reasons for blogging/tweeting ‘anonymously’ are as follows
    I am currently engaged in clinical work with people which can be very sensitive. I feel a need to protect the work I do above all things and while I never tweet/blog about work I do, I wouldn’t want to do anything that might put that at risk.
    Using your name when you are in a training/administrative/management role is different because you have either a process of wanting to link your words with your identity to build authenticity or you have a seniority in our organisation which allows you more freedom.
    As a bog standard frontline practitioner, I feel much more vulnerable regarding my ‘real name’.
    In some ways, I want to stand and for my authority to be defined by what I say, the way I say it and the way I interact, rather than my name. I hope I do that. I’ve seen some people around who claim a professional status whose words/actions/responses seem to be anything but. A degree of scepticism is very useful in the arena where we move away from face to face contact.

    I have also been subject to abuse as I identify as a ‘social worker’. Some people have perceptions of the profession and what we do that is inherently negative. I want to afford myself a little protection from becoming the target of many people who have had negative experiences with ‘social services’ broadly (incidently, most of the abuse has been about ‘removing children’ and ‘being a nazi’ and I’ve always worked in adult and mental health services).

    I am happy and indeed, welcome people treating me with scepticism. It’s a well thought out and considered choice I’ve made. I’m sure the name and the identity will blur at some point but it has to be an active choice I make rather than forced upon me.

    • What a wonderful response! So not so much about boundaries, or is that what you mean by putting your work at risk?

      • I think I just caught in a tangent. Boundaries come into it although I’m actually confident about my being able to manage boundaries regardless of being named or not so that’s not really what my concerns are about..

        By ‘putting my work at risk’ I think I meant it more in terms of distraction. I don’t want to be ‘that social worker with a blog’ or ‘that social worker on twitter’, I want to be ‘that social worker who is wholly concentrating on my needs’. Not that being on Twitter/blogs etc detracts. Conversely i think it adds but if there’s a smidgeon of concern in anyone’s mind when I see them that I may use my experiences online (I don’t – I never discuss any specific work and certainly no person I work with – even anonymised) I worry about that in terms of therapeutic intervention. Possibly my own paranoia. I’m willing to accept that!

    • Thank you for this Ermintrude. Very thoughtful response. I am most struck by your absolute integrity when it comes to your central concern of avoiding even the slightest possibility of compromising your relationship with people you support. I agree that it is different tweeting and blogging in a managerial/administrative capacity although I am aware it creates similar risks in relation to becoming a target for negativity, which I’ve been sensitive to from time to time. I completely respect your position and have come to the conclusion that people need to make their own personal decisions about how they present themselves online, and that this will be different for different people. We are all putting on a performance, choosing to present certain aspects of ourselves, and choosing to obscure other parts,whether using anonymous identities or otherwise.

  6. i find this very thought provoking and a great topic.even if someone says they are a proffessional how could we know,we may want to accept that they are because maybe we agree with what they say or maybe because they dissagree with someone we may not like.
    i really do think this is an excellent topic,personally i have one account-true picture and real identity,i dont claim to be anything or anyone that i am not or indeed my experience,advice is exactly that and people can interprate that in any way they choose just like any other persons advice.
    i do not have a mental health issue myself and certainly not a personallity disorder,i will continue to be upfront,forthright and totally honest about what i tweet,i even give my email to people so i certainly have nothing to hide or a reputation true or otherwise
    to protect nor do i have a huge ego,which some appear to have.
    a brilliant piece

    • Thank you for your comments Mike. Issues around honesty and trust are important issues online and perhaps trickier to work out than in an offline context.

  7. Thanks for your lovely reply Victoria. Just got me thinking a bit more….on a personal level the blog(s) I keep are to do with my geeky quirks and interests such as knitting, creating and home birth! I am however extremely proud of these interests – but wouldn’t want to be ridiculed by non-like minded people at work, saying that being fairly outspoken and outgoing most people in my team would know about these things anyway….so I’m not sure what I’m really worried about!
    I think we need to work on losing the ‘fear’ culture in the NHS and as a staff group take more positive risks to be proud of who we are and the diversity of people running services. A service which is digitally engaged sounds really exciting and innovative. Working in this way we can positively change people’s concepts of what we do and what working in MH is all about. It might also help people to change their values and attitudes at work and open new pathways that might not have been previously considered before for fear of stepping outside set boundaries….all interesting stuff, I’m excited to see this develop 🙂

  8. Hi Victoria (in the interests of full disclosure I do have the honour of knowing Victoria professionally!)

    Personally I think it’s extremely difficult to map a whole ‘real-life’ personality onto an online profile on just one particular social media platform. Google+ and Facebook obviously tried to respond to this by allowing people to share certain things with only certain groups, just as people do in real life. With Twitter though, it’s either your real name against every ill-advised drunken 2am declaration of love for the music of Bananarama, or you’re just a ‘safe’ pseudonym.

    Tonight on Twitter there were two simultaneous chats going on. #MHChat were talking about Social Anxiety – something I have more personal experience with than I’d ideally like. #nhssm were talking about working with online service user/carer feedback – something I have quite a fair bit of professional experience with. I like to think I’d have had valuable (or at least relevant) stuff to contribute to one of those chats, if not both.

    But I confess, I didn’t really feel comfortable joining in with either. My (anonymous) Twitter feed is not something I use to talk about MH difficulties, nor is it a place where I talk about work. It is mainly a place where I swear quite a lot about random annoyances. It is cathartic and fun, I follow some brilliant people and have met great people through it, and it definitely reflects one side of my personality.

    But anyone from those chats checking back through my timeline would be entitled to ask, “Eh? Who/what are you and why are you here? You never normally talk about ANY of this stuff?” So contrary to becoming anonymous I’m now giving serious consideration to setting up a grown-up Twitter account, where I use hashtags like #socmed and #mh rather than #drwho and #wine.

    I don’t think people who use services expect NHS staff to be saints in their own time, either offline or online. And personally I find the idea of a consultant psychiatrist tweeting about their love of Bananarama at 2am quite humanising and endearing to be honest. But if they’re YOUR consultant psychiatrist, and you see it – then of course that could create boundary issues! Or even lead to you going your separate ways due to musical differences.

    I think there are enough social media platforms for professionals to be able to compartmentalise their online personality should they so wish; for me I see the risk as trying to do it all in one profile.

    • Hi Al. Thank you for your comments on my post. I hadn’t quite thought of the whole subject in relation to the pitfalls of a Bananarama crush going viral but you have helped me to see if from a whole new vantage point. And now I’m scared… Similarly to you, the seduction of an anonymous account is more about an urge to be silly than anything else. However, I can see that this then prevents you from engaging in grown up sensible stuff that you may also be interested in. There’s an interesting issue about what we choose to share about our personalities in a work context, or indeed online, and what we don’t. This has come up a few times in responses. I do try and do both in one profile but with a relatively high degree of self-restraint. I’ll look forward to meeting the sensible you on Twitter sometime soon!

      • Oh sensible online me is *ghastly*! It’s like real-life me, but in undeletable text form!

        For what it’s worth I don’t think I could walk the line as well as you do with one account! And for me there’s also a question of work/life balance – I had a personal online presence(s) for years before this stuff was being talked about, and I suppose I’m reluctant to now just have that completely subsumed into the “I’m always an employee” mindset.

        But work/life balance and social media is a whole other question…!

        • cheers! you’ve just given me my next blog post material:-)

  9. I’ve enjoyed reading the original blog and comments – although I started out with an identifiable avatar and stated I was a nurse, I never said where. In some ways the ‘worst’ of both worlds – I couldn’t take the route of cathartic outpouring (and heaven forbid a wee swearie word) neither could I engage directly with people with whom I shared interests. In became clear, rather quickly, that this was a pointless position to adopt. My bio says who I am and where I work – I’m now free to say whatever I like that is consistent with my duty to uphold my professions ‘image’ and with the clear parameters of my role. This means my online persona is congruent with my offline one.

    It is easier for me than e.g. Ermintrude2, given that I’m not in day to day F2F clinical practice – I respect the position E2 has adopted – and yes, E2’s words/language and responses ARE sufficient authentic authority for me.

    Great blog – thanks.

    • Thank you for your commenting on my blog post and all the subsequent comments (which I think are far more insightful than my original post BTW…). I think I may have started off with two Twitter accounts at first but quickly ditched one of them when I realised it was large amounts of effort to keep up with them, if nothing else. I am similar to you in that congruence is what I’m aiming for but probably with a little more sweariness offline than on 🙂

  10. Wow, your posts are always so thought provoking! They really make you think! I’ve just started tweeting and blogging recently and sometimes I really really want to express my thoughts and share ideas about work related activities but I’m always conscious that I may get into trouble with IP issues and litigation so I avoid it.

    This is good stuff – keep the posts coming I think I’m actually growing brain cells!

    • Thank you for your kind words Imran. I’ve really enjoyed the conversation stimulated by this blog post and I am fascinated by the plethora of different reasons behind the choices people make about what they choose to share about themselves on social networks. Hope your tweeting and blogging continues to blossom! Victoria 🙂

      • You’re welcome Victoria. Thank you for the well wishes 🙂


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