Psychotherapy, Online Social Networking, and Ethics

 

With each passing day technology plays an increasingly important role in the lives of both psychotherapists and those we serve. The Internet, E-mail, social networking sites, chat rooms, professional E-mail lists, and the like each impact how we live, work, communicate, and relate to each other. While it may seem that how psychotherapists utilize various technologic advances in our personal lives is not an ethical issue, in the digital world in which we now live there is no clear boundary or line of separation between our personal and professional lives. As will be presented, the use of social networking sites by psychotherapists (professionally and/or personally) and by their clients presents a unique set of ethical challenges and dilemmas.

Ethics and the Internet

The Ethical Principles of Psychologists and Code of Conduct (Ethics Code; APA, 2002) states clearly that: “The Ethics Code applies to (professional) activities across a variety of contexts, such as in person, postal, telephone, Internet, and other electronic transmissions” (p. 1061). Additionally, the APA Ethics Committee has promulgated the Statement by the Ethics Committee on Services by Telephone, Teleconferencing, and the Internet (APA, 1997) in recognition of the growing role technology plays in clinical practice. The Canadian Psychological Association (2008) developed the Ethical Guidelines for Psychologists Providing Psychological Services Via Electronic Media to address the ethical challenges and dilemmas often associated with utilizing the Internet. Further, the International Society for Mental Health Online has promulgated the Suggested Principles for the Online Provision of Mental Health Services (2000). Thus, it is clear that psychotherapists should give thought to the role and impact of the use of electronic media in their professional roles and use these documents to inform these decisions. Familiarity with relevant ethical standards and practice guidelines and careful consideration of the impact of the use of various online media are important for each practicing psychotherapist.

Even with thoughtful utilization of available resources, psychotherapists may face a myriad of ethical challenges and dilemmas regarding the role of social networking sites in our professional and personal lives that will require our careful consideration. Examples include:

• A seasoned psychotherapist receives an E-mail invitation to join a social networking site. The site obtained his name and E-mail address from one of his clients, who hoped to learn more about the clinician by “friending” him on the site.
• A supervisor performs a Google search on one of her graduate student supervisees and finds a link to a profile he keeps on a social networking site. She views his profile and finds many pictures of him in bars holding and drinking alcoholic beverages.
• An early career psychologist who utilizes a social networking site to keep in touch with family and friends receives a “friend request” from a former client she treated for six months during her graduate training.

Social Networking Sites

Social networking sites (SNSs) are described as “interactive websites designed to build online communities for individuals who have something in common – an interest in a hobby, a topic, or an organization – and a simple desire to communicate across physical boundaries with other interested people” (Carter, Foulger, & Ewbank, 2008, p. 682). The most popular of these is Facebook, although others, such as LinkedIn and Friendster, also have followings, albeit to a lesser extent (Salaway & Caruso, 2008).

As part of their online networking practice, users typically post personal information about themselves that may include educational, occupational, and contact information, as well as descriptions of their interests and activities. Many users also post photographs of themselves alone and/or in groups. Users may communicate with each other by leaving messages on one another’s pages or merely learn more about other users via viewing their personal profiles. While these sites are typically used for general networking purposes, some appeal to particular interests (e.g., LinkedIn’s primary aim is career networking) or populations (e.g., Facebook initially limited its membership to undergraduates, who continue to comprise the bulk of its members; Salaway & Caruso, 2008).

The sharing of personal information across as public a medium as the Internet brings with it a number of risks, and users are wise to recognize that abuse or simply negligent use of these sites may have deleterious effects. For example, revealing excessive personal information without implementing sufficient privacy controls has led to fear of identity theft and Internet stalking. Additionally, the prominent case of Megan Meier, the 13-year-old girl who committed suicide in 2006 after receiving harassing messages on MySpace from a user who had created a fraudulent profile, has made the potential impact of SNSs in users’ lives and social functioning devastatingly apparent. Conversely, it appears as though SNS usage may also have positive social effects. Ellison, Steinfeld, and Lampe (2007) found that Facebook utilization was positively related to the amount of social resources (“social capital”) enjoyed by undergraduate students. This effect was exaggerated in students who reported lower levels of life satisfaction and self-esteem, suggesting the particular usefulness of SNS usage for individuals with social struggles offline.

Patterns of Social Networking Site Use

An extensive survey conducted by the Educause Center for Applied Research (Salaway & Caruso, 2008) yields statistics on SNS usage that make the phenomenon impossible for psychologists to ignore. The findings indicate that the vast majority (85.2%) of all undergraduate students frequent at least one SNS, with membership comprised of a greater proportion of younger students than older students (i.e., fully 95.1% of 18-19 year old students report SNS usage, compared with only 37% of undergraduates aged 30 years or more). Furthermore, 56.8% of respondents make SNS usage a part of their everyday activities, up from 32.8% in 2006, which demonstrates the recent and considerable rise in the integration of SNSs in users’ daily functioning. The most frequently reported purpose of SNSs is to maintain connections with existing friends and acquaintances (96.8%); just 16.8% make use of these sites to foster entirely novel friendships. In addition, more than half of respondents use these sites to gather more information about people they may or may not have met (51.6%) and to share photographs, videos, and other media (67.7%).

Yet, SNS use is not limited to undergraduate students. Facebook presently has more than 175 million registered users worldwide. More than 3 billion minutes are spent on Facebook each day and more than 18 million users update their page each day (Facebook, 2009). MySpace presently has more than 185 million registered users worldwide. Approximately 25% of all Americans are active MySpace users. Almost 350,000 individuals sign up as new users of MySpace each day and it has achieved more than 4.5 billion page views in a single day. Over 1.5 billion images are shared via MySpace each day. Fifty million mails are sent each day through MySpace and there are over 10 billion active friend relationships at present (Social Network Stats, 2008). The ubiquitous nature of SNSs in the lives of so many is quite evident from the above data.

Ethical Challenges and Dilemmas

The use of SNSs by psychotherapists and their clients raises a number of ethical challenges in areas that include informed consent, boundaries, self-disclosure, and multiple relationships. Boundary violations and multiple relationships are inherent concerns when considering SNSs for psychotherapists. Practitioners who utilize these sites may receive online requests from their clients to become “friends” on these sites, and accepting these requests necessarily blurs the lines of the therapeutic relationship. Although it is generally accepted that “friends” on SNSs are often mere acquaintances, the title may still complicate expectations of the relationship and the role of the psychotherapist in the client’s life. Although befriending a client online does not necessarily constitute an exploitative multiple relationship (See Standard 3.05 of the APA Ethics Code), it may be the first step in a series of increasingly inappropriate communications or disclosures that are not consistent with anticipated professional roles.

Declining the client’s ‘friend’ request may be a clinical challenge and may have some impact on the psychotherapy relationship and process if not addressed appropriately. While it seems as though the simple solution to this dilemma is to either limit search options or refrain from using SNSs altogether, even these precautions may not eradicate the issue: current or former psychotherapy clients may send electronic membership invitations to clinicians who do not already have a SNS listing (as illustrated in Scenario 1 above). For those who have a SNS the use of different levels of security settings may prevent clients from having free access to the psychotherapist’s online materials, but the existence of the online profile is usually not hidden and clients may still request being accepted as a friend. Further, some clients who are very computer savvy may be able to circumvent security settings and obtain access to information intended only for personal use.

In some ways, friend requests and membership invitations may be viewed as auspicious, as they may indicate that the client considers the therapeutic relationship to be a strong one. They may also indicate a client’s desire to share personal information with the clinician that is relevant to the psychotherapy and this may be a valuable contribution to the psychotherapy process (Lehavot, 2009). In such cases, it may be possible to view the client’s online materials together and process them as part of the ongoing therapeutic process. Alternatively, friend requests may indicate a client’s suspicion of the clinician or simply a boundary crossing to obtain more information about the psychotherapist’s personal life to quell curiosity. Regardless, such an event should be addressed in psychotherapy in order to determine the impetus for the request and the client’s reaction if the psychotherapist chooses to decline the invitation. As Lehavot (2009) states: “By paying thoughtful attention to the function of the client obtaining information about the clinician online, the psychotherapist can examine this behavior as an opportunity to enhance the client’s treatment” (p. 28).

It should be pointed out that sharing information with a client in itself is not necessarily unethical. Psychotherapists have the right to decide how much personal information they are comfortable sharing with clients. But, psychotherapists should also consider the impact of such online relationships on the psychotherapy relationship and process. Considering these issues and their potential consequences before they become an issue with a particular client is recommended.

Issues of informed consent arise when clinicians decide to conduct online searches for their clients without their knowledge or prior approval. While one may argue that viewing a client’s profile can be useful clinically insofar as it may provide clinicians with additional or corroborating data to enhance understanding of various aspects of the client’s life, doing so clandestinely may have substantial negative implications for rapport. For example, if a psychotherapist learns of a client’s experimentation with illicit substances online and the client has not disclosed this in treatment, what does the psychotherapist do with this information? Should one disclose their search and what they have learned, accepting any negative impact on the therapeutic relationship, or should one withhold the information and not address in treatment a potentially significant clinical issue? Similar issues are relevant for supervisors who search for information about their supervisees online (as depicted in Scenario 2 above). Psychotherapists and supervisors should consider issues of trust as well as professional role modeling when considering these decisions.

It should be noted that psychotherapists vary in their perceptions of the clinical impact of self-disclosure, multiple relationships, and boundary crossings and will vary in their comfort level with the intersection of SNSs and their clinical practice. Williams (1997) has pointed out that the clinician’s theoretical orientation may impact views of the appropriateness and use of psychotherapist self-disclosure. Humanistic psychotherapists may be more open to the use of self-disclosure to make themselves appear more genuine and to narrow the power differential between clinician and client. In contrast, psychoanalysts and psychodynamic psychotherapists may prefer less transparency with their clients to promote the transference relationship and thus may utilize self-disclosure much more sparingly. Williams importantly portends the possibility of ethically incorporating SNS usage into clinical practice in his suggestions for a thoughtful and flexible approach to boundaries and self-disclosure. Still, if clinicians decide to use SNSs professionally, they are encouraged to do so only after carefully weighing costs and benefits and proceeding with appropriate caution so that the standards of the APA Ethics Code may be upheld and clients’ best interests are addressed.

It is, however, important to keep in mind that in the Internet age, many clients are likely to search for information about their psychotherapist. This will likely be true regardless of one’s decision to participate in SNSs given that individuals have been encouraged in recent years to become more informed consumers of services and to be more actively involved in their care, and that use of the Internet for such purposes is prevalent. Psychotherapists should anticipate this occurring. In fact, one recent survey of consumers found that 80% of all Internet users have searched for health care information online to include information about specific health care professionals (Fox, 2005).

Cohort Effects

Seasoned Professionals

While some senior psychotherapists may be active online, many may feel unaffected by the SNS trend in terms of its influence on their ethical practice by virtue of the fact that relatively few of them participate in online social networking. Many, although clearly not all, may also be unaware of the pervasive effects of the SNS trend, given that they came of age in a different time. However, the issue remains an important one consider, especially when treating clients who are active on the Internet. For seasoned professionals, limited familiarity with SNSs may restrict their ability to comprehend the social substrate in which many of their clients function, particularly those in the net generation. These clients are so-called “digital natives” (Prensky, 2001) in that they have been raised in an electronic culture, speaking a digital language that is foreign to many “digital immigrant” seasoned professionals. Given the widespread use of SNSs, it is prudent to obtain at least a general awareness of the purpose, features, and potential risks and benefits of these sites so that we are able to converse with clients and understand the world in which they function.

Students and Trainees

The psychology graduate student cohort is arguably the one within our profession most associated with the SNS trend. They are in a unique position as budding professionals in the field in that SNSs are already largely a part of their social lives; that is, many trainees were undergraduates when the social networking craze began and initially thrived on college campuses (e.g., Facebook was launched in 2004). As such, the next generation of psychologists has been largely immersed in the culture of online social networking and likely hadn’t considered issues of professionalism in social networking prior to entering graduate school. The recent concern about psychology graduate students’ lives on the Internet has been mirrored by similar concerns in the medical (Thompson et al., 2008) and teaching (Carter, Foulger, & Ewbank, 2008) professions.

Trainees should very carefully monitor and consider the information they include in their online profiles. While it is necessary for all practitioners to be cognizant of the information they share online, many trainees will have developed a profile prior to their involvement in the field of psychology. For that reason, it is recommended that trainees review all material on their profiles in order to determine its appropriateness and make alterations as needed. For example, online videos, photos, and writings that seemed very appropriate for an audience of peers when a college sophomore may not be viewed in the same manner by graduate school admissions committee members or even by undergraduate faculty who are asked to write letters of recommendation. Then, when in graduate school, one’s online presence may impact externship and internship decisions. Graduate student psychotherapists-in-training must also consider the potential impact of their online presence on their clients.

Recommendations

Psychotherapists should consider all online posts they make and profiles they keep to be self-disclosures, even if precautions are taken by setting privacy controls on SNSs. Clinicians are encouraged to remain cognizant of the fact that even if a given disclosure is not unethical per se, it still may have an impact clinically; that is, anything that is put on the Internet may influence our professional roles and relationships. Furthermore, although the Ethics Code only technically pertains to professional endeavors, materials placed on the Internet for personal relationships cannot be kept completely separate from our professional roles. Additionally, information accessed about psychotherapists in our personal lives may impact the public’s view of us professionally as well.

It is recommended that psychotherapists maintain professional websites so that clients who search for us via the Internet will access the information shared there that is of relevance to our professional roles and activities. Information shared may include credentials, training experiences, areas of specialization and populations worked with, and related professional information (Barnett & Hillard, 1999). Always consider the meaning of “friend” requests from clients in the context of their psychotherapy. When appropriate, use joint review of the SNSs as a therapeutic activity. That is, if a client has invited a psychotherapist to be their “friend” online in order to share personal information, photos, or other media, suggest the option of having the client log on to their profile during session so that the profile viewing may be done together. This may help ensure a minimal likelihood of boundary violations or threats to trust and guarantees that the online content may be jointly explored and processed in session.

Consider the option of prescribing SNS use to clients to address certain challenges they may have, either as a primary intervention or as a supplement to other, more traditional strategies. For example, a client who is struggling to find a worthwhile career path may engage in standard career counseling as well as become involved in LinkedIn.com, which is largely devoted to professional development.

Teaching professionals should include their policy statement on online searches of applicants and students in their program materials. Additionally, expectations for student professionalism with regard to their online presence and activities should be included in student handbooks and be reviewed beginning at orientation and reviewed throughout their training. Assisting trainees to make the digital transition from the purely personal to the professional is an important role for supervisors and faculty.

References

• American Psychological Association. (1997). Statement by the Ethics Committee on Services by Telephone, Teleconferencing, and the Internet. Available at: https://www.apa.org/ethics/stmnt01.html. Accessed March 23, 2009.
• American Psychological Association (2002). Ethical Principles of Psychologists and Code of Conduct. American Psychologist, 57, 1060-1073.
• Barnett, J. E., & Hillard, D. (1999). Therapist self-disclosure: What should I say? What can I say? What do I say? In J. Barnett (Ed.), Maryland Psychological Association Ethics Manual (pp. 70-71). Columbia, MD: Maryland Psychological Association.
• Carter, H. L., Foulger, T. S., & Ewbank. A. D. (2008). Have you Googled your teacher lately? Teachers’ use of social networking sites [Electronic version]. Phi Delta Kappan, 89(9), 681-685.
• Ellison, N. B., Steinfeld, C., & Lampe, C. (2007). The benefit of Facebook “friends”: Social capital and college students’ use of online social network sites. Journal of Computer-Mediated Communication, 12, 1143-1168.
• Facebook. (2009). Statistics. Available at: https://www.facebook.com/press/info.php?statistics. Accessed March 23, 2009.
• International Society for Mental Health Online. (2000). Suggested principles for the online provision of mental health services. Available at: https://www.ismho.org/suggestions.html. Accessed March 23, 2009.
• Lehavot, K. Is being exposed all bad? Implications of Internet self-disclosures for psychotherapists, clients, and graduate students. In Zur, O., Williams, M., Lehavot, K., & Knapp, S. (2009). Psychotherapist self-disclosure and transparency in the Internet age. Professional Psychology: Research and Practice, 40(1), 22-30.
• Prensky, M. (2001). Digital natives, digital immigrants. On The Horizon, 9(5), 1-6.
• Salaway, G., & Caruso, J. B. (with Nelson, M. R.). (2008). The ECAR Study of Undergraduate Students and Information Technology, 2008 (Research Study, Vol. 8). Boulder, CO: EDUCAUSE Center for Applied Research. Available at: https://www.educause.edu/ecar . Accessed January 7, 2009.
• Social Network Stats. (2008). Social networking site usage: Visitors, members, page views, and engagement by the numbers in 2008. Available at: https://www.web-strategist.com/blog/2008/01/09/social-network-stats-facebook-myspace-reunion-jan-2008/. Accessed March 23, 2009.
• Thompson, L. A., Dawson, K., Ferdig, R., Black, E. W., Boyer, J., Coutts, J., et al. (2008). The intersection of online social networking with medical professionalism. Journal of General Internal Medicine, 23(7), 954-957.
• Williams, M. H. (1997). Boundary violations: Do some contended standards of care fail to encompass commonplace procedures of humanistic, behavioral, and eclectic psychotherapies? Psychotherapy, 34, 238-248.

 
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