Welcome to ‘CE Corner'
"CE Corner" is a quarterly continuing education article offered by the APA Office of CE in Psychology. This feature will provide you with updates on critical developments in psychology, drawn from peer-reviewed literature and written by leading psychology experts.
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Upon successful completion of the test — a score of 75 percent or higher — you can immediately print your CE certificate. The test fee is $25 for members and $35 for nonmembers. The APA Office of CE in Psychology retains responsibility for the program. For more information, call (800) 374-2721.
CE credits: 1
Exam items: 10
After completing this course, participants will be able to:
- Explain the relevant ethical concerns associated with participating in online social networking websites.
- Clarify concerns and limitations of privacy associated with increased Internet transparency.
- Describe best ethical practices for psychologists who use social networking websites.
Too often, people don't think twice about disclosing their personal information online. In fact, many frequent users of social networking websites willingly divulge scads of private data — including where they live and whom they are attracted to — often under the false assumption that no one else can see that information (Strater & Richter, 2007). Many people also initiate online relationships, even if they aren't sure they can trust the people they meet online (Dwyer, Hiltz, & Passerini, 2007).
"Users are communicating in their virtual underwear with few inhibitions," as David Rosenblum put it in IEEE Security and Privacy (2006).
What is the psychologist's role in this burgeoning era of communication? First and foremost, psychologists must be knowledgeable about and open to this new digital culture, while also maintaining their values and ethical principles.
Of course, the contrast between psychotherapy and social networking sites could not be starker. Most psychotherapeutic interactions are private and confidentially protected, while most interactions on social media are broadcast to the public or to a network of friends. But when psychologists interact in both spheres, they do risk violating clients' confidentiality or crossing boundaries.
Guidance for dealing with such risks comes from what at first glance may seem an unlikely source: rural psychologists (Lehavot, 2010; Zur, 2006; Zur, Williams, Lehavot & Knapp, 2009). These professionals are, however, a great resource since they have been navigating dilemmas surrounding self-disclosures and boundary violations for years (Hargrove, 1982, 1986; Hargrove & Breazeale, 1993).
This article offers their wisdom for psychologists working with clients in today's era of online communication.
Social networking and professional psychology
Social media is a broad term that refers to websites that enable the creation and exchange of user-generated content online (Kaplan & Haenlein, 2010). These websites include, but are not limited to:
- Social networking sites, such as Facebook, MySpace and LinkedIn.
- Publishing media, such as Wordpress, Blogger and Wikipedia.
- Content sharing, such as YouTube, Flickr, Digg and Last.fm.
- Discussion sites, such as Yahoo Messenger, Google Talk and Skype.
- Microblogging, such as Twitter, Tumblr and Posterous.
- Livestreaming, such as Friendfeed and Lifestream.
- Livecasting, such as Livestream.
- Virtual worlds, such as Second Life and There.
The use of social networking websites has rapidly increased in recent years and is becoming normative for the American population. Madden and Zickuhr (2011) of the Pew Research Center found that 65 percent of online adults — or 50 percent of all adults — use these sites. This is an increase from 8 percent of online adults using social networking sites in 2005 and an increase from 46 percent of online adults using social networking sites in 2009 (Lenhart, 2009).
Facebook — the most used of these sites among Americans age 18 and older — is accessed by 901 million monthly active users worldwide. More than 527 million users log on to Facebook on any given day (Facebook, 2012c).
Psychological professionals also increasingly use social networking sites (Taylor, McMinn, Bufford, & Chang, 2010). Among psychology graduate students, Lehavot, Barnett, and Powers (2010) found that 81 percent reported having an online social networking profile, and 33 percent of those students used Facebook. APA also uses social networking sites to promote the field and communicate with large numbers of people. The association has more than 75,000 followers on Facebook, for example (Facebook, 2012a).
Data suggest there are age differences in who uses these sites. Madden and Zickuhr (2011) found that younger Americans are significantly more likely than any other age group to use social networking sites, with a usage rate of 83 percent for adults ages 18 to 29. Even though older adults use these sites less frequently, their use is increasing. In 2011, 33 percent of adults age 65 and older used social networking sites, a 150 percent increase from 2009 (Madden & Zickuhr, 2011).
Age differences in online activity are present among psychologists as well. Taylor et al. (2010) found that although more than three out of every four doctoral-level psychology students use social networking sites (often to communicate with friends and family), most established psychologists do not often use them.
Because of their increased online presence, younger psychologists may be inviting online dilemmas more often than their more seasoned colleagues. It is also possible that experienced psychologists — who often serve as supervisors, instructors and consultants to newer psychologists — may not be adequately equipped to address many of the online problems that occur among younger colleagues and trainees due to their lack of experience with the new technology.
Indeed, there is evidence that younger professionals may already be navigating these ethical waters with limited guidance. Chretien, Greysen, Chretien and Kind (2009) found that 60 percent of medical schools in their sample reported instances of medical students posting unprofessional online content, which included disclosure of patient confidentiality, profanity, discriminatory language, depiction of intoxication and sexually suggestive material. Furthermore, DiLillo and Gale (2011) found that 98 percent of doctoral psychology students had searched for at least one client's information over the past year, even though most reported that searching for clients online was "always" or "usually" unacceptable.
Applying small world ethics
Social networking sites may be ushering in a "small world" online environment that is analogous to "small world" rural settings where psychologists have encountered more transparency than their urban counterparts for years (Hargrove, 1982, 1986; Helbock, Marinelli & Walls, 2006; Morrison, 1979; Roberts, Battaglia & Epstein, 1999). Although the landscapes of social networking sites and rural environments are very different, there are important similarities. Both are characterized with pervasive incidental contact, inevitable self-disclosure and unavoidable multiple relationships. For example, just as people in rural areas may know where the local psychologist lives or frequents, some social networking sites tag photos with exact GPS coordinates of where they were taken (Nicholson, 2011).
Small world ethical thinking refers to a psychologist's heightened awareness that his or her environment will likely produce ethical dilemmas surrounding boundary violations related to online realities such as greater transparency, increased self-disclosure and unavoidable multiple relationships. In rural settings, completely avoiding self-disclosures and multiple relationships is not always possible (Brownlee, 1996; Campbell & Gordon, 2003; Roberts et al., 1999; Zur, 2006). Nevertheless, rural practice has demonstrated that certain boundary violations can be managed or prevented (Faulkner & Faulkner, 1997).
Preventing and managing boundary violations online
Psychologists are guided and inspired by three fundamental ethical principles that apply directly to setting appropriate boundaries online: beneficence, nonmaleficence and integrity (APA, 2010; Beauchamp & Childress, 2001). Together, these principles help flesh out APA Ethical Standard 5.04, which advises psychologists to take appropriate precautions regarding their dissemination of public advice and comments via media that include the Internet. First, psychologists must consider the risks and rewards that their online activity might pose for their clients. Second, the principle of integrity inspires psychologists to be upfront and honest in therapy about the potential role confusion that could occur with online interactions with clients.
Overall, it is important for psychologists to recognize that their "private" online activity may intersect with their professional competence. Indeed, online self-disclosures may represent the intersection where dilemmas surrounding personal and professional roles meet — in some cases signaling the start of boundary violations. Kaslow, Patterson and Gottlieb (2011) noted that with self-disclosure online, "the client's perception of the relationship may become a more casual or even social one that may violate the boundaries or context of therapy as a sanctuary for exploring personal issues." Zur et al. (2009) noted that self-disclosures may have implications for therapeutic outcomes and can occur in three ways:
- Deliberate, in which disclosures are intentional and avoidable.
- Unavoidable, in which disclosures are inescapable but generally expected.
- Accidental, in which disclosures are both unavoidable and unexpected.
Unfortunately, self-disclosure online is almost inevitable (Zur, 2008). Often it is initiated by clients who want to learn more about their therapists. Some clients may do more than a Google search: They may join social networking sites, join professional listservs/chat rooms, or pay for online background checks or online firms to conduct illegal, invasive searches (Zur, 2008; Zur et al., 2009). Lehavot et al. (2010) found that 7 percent of student psychotherapists reported that a client disclosed that he or she obtained online information about them.
To help keep clients from being able to gather such information, psychologists should determine just how private the social networking sites they use are. Unfortunately, many social networking site users don't realize how insecure their online personal information is (Barnes, 2006). Strater and Richter (2007) found that college students showed an all-or-nothing approach to online privacy, either actively managing their privacy standards strictly or not at all. This would be a disturbing trend if psychologists had the same outlook (Zur, 2008; Zur et al., 2009). Clients could, for example, discover information about a therapist's private phone numbers and addresses, household composition, the value and structure of a psychologist's home (and photographs), ratings of a therapist by other clients, blog postings, personal images, videos, professional and personal websites, news articles written by or about therapists, professional publications and research articles, and links to social media profiles. As a result, psychologists should be careful about what personal information they post online.
Psychologists can help prevent online boundary violations by becoming familiar with the nature of multiple relationships (Barnett, Lazarus, Vasquez, Moorhead-Slaughter & Johnson, 2007; Borys & Pope, 1989; Ebert, 1997; Pipes, 1997) and ethical decision-making models (Gottlieb, 1993; Kitchener, 1984). According to APA (2010), multiple relationships occur when a psychologist is in a professional role with a person and either is simultaneously in or promises to be in another role with that person or someone closely associated with that person.
Barnett et al. (2007) said that to avoid being exploited by clients, a psychologist must make sure that he or she does not enter into multiple relationships designed to meet the psychologist's own needs. Kitchener (1988) recommended that psychologists consider three issues that increase the risk that multiple relationships will harm clients: incompatibility of expectations between client and psychologist, increased commitments in non-therapeutic roles, and power differentials between psychologist and client.
Ethical dilemmas in rural areas offer insight into the problems social networking site users can expect to encounter online. Schank and Skovholt (1997) described four types of rural dilemmas that involve multiple-role relationships. These occur when there are overlapping social relationships, business/professional relationships, relationships involving the psychologist's family, and relationships involving the psychologist's clients with other clients. Certain problems unique to the Internet that may become more common with the increased use of social networking sites are those related to dating websites: Taylor et al. (2010) described unsettling situations in which psychologists in training had either matched with current/former clients through anonymous dating websites or found pictures of clients on the websites of family and friends.
Suggestions for best practices online
Although social networking sites offer meaningful ways to connect with family and friends (Bratt, 2010), psychologists must be sure that they use them in ways that benefit their clients, themselves, and the reputation of psychological practice. Here is some advice.
Managing boundaries online
It is particularly important to set appropriate boundaries with clients to avoid conflicts of interest (Canadian Psychological Association, 2008). To do this, a psychologist may need to create and maintain a formal social networking site policy as part of the informed consent process (Barnett, 2008; Burke & Cheng, 2011; Damsteeg, Murray & Johnson, 2012; Lehavot et al., 2010; Tunick, Mednick & Conroy, 2011). Since APA does not offer guidelines on social networking site use, it may be helpful to consult policies of other health organizations. According to the American Counseling Association (2005), informed consent processes should at the very least acknowledge the risks and benefits of using social media and other technology. In addition, such policies could lay out psychologists' expectations for using such sites, namely that practitioners do not "friend" or interact with clients on social networking sites (Kolmes, 2010). Practitioners should also inform clients that they do not search for them online, unless the client has given consent or it is part of a clinical treatment plan (Barnett, 2008; Clinton, Silverman & Brendel, 2010; Lehavot et al., 2010; Tunick et al., 2011).
In addition, in most cases psychologists should avoid forming multiple relationships with clients online (American Medical Association, 2010; Bratt, 2010). Yet, understanding that there may be necessary exceptions to this guideline, psychologists who confront a multiple relationship dilemma may want to consider Younggren and Gottlieb's (2004) questions:
- Is entering into a relationship in addition to the professional one necessary, or should I avoid it?
- Can the dual relationship potentially harm the patient?
- If harm seems unlikely or avoidable, would the additional relationship prove beneficial?
- Is there a risk that the dual relationship could disrupt the therapeutic relationship?
- Can I evaluate this matter objectively?
Many practitioners may not realize that they may be committing a boundary violation by searching for a client on Google without his or her permission. As a result, practitioners may want to develop self-monitoring strategies, such as consulting with colleagues and supervisors (Gabbard, Kassaw & Perez-Garcia, 2011). Clinton, Silverman and Brendel (2010) offer six questions that practitioners can ask themselves to help determine whether to Google a client/patient:
- Why do I want to conduct this search?
- Would my search advance or compromise the treatment?
- Should I obtain informed consent from the patient?
- Should I share the results of the search with the patient?
- Should I document the findings of the search in the medical record?
- How do I monitor my motivations and the ongoing risk-benefit profile of searching?
It may also be prudent for psychologists to separate their professional and personal profiles online on social networking sites (American Medical Association, 2010; Myers, Endres, Ruddy, & Zelikovsky, 2012), including only professional information on professional social media profiles (Bratt, 2010). Finally, because of the transparent nature of social networking sites, discussions of client case studies online should be done extremely cautiously, if not avoided altogether (Van Allan & Roberts, 2011).
Developing online technological competence
Just as it is necessary for psychologists to understand the cultural context of where they live and work, they must also understand the nature and requisite technology of social networking sites. It is also important for psychologists to understand social media since their clients are likely to use it (Myers et al., 2012).
First, psychologists would be wise to be aware of what information clients can see online. One way to do that is to periodically search for your own name online to determine what clients might find (Taylor et al., 2010; Zur, 2008), or even to set up Google alerts to find out immediately when your name is mentioned in a new online posting (Zur et al., 2009). In addition, Facebook users are now able to download their information to see what information the site holds (Facebook, 2012b). Practitioners who discover inappropriate personal information online may want to contact the person who posted the information and/or the website administrator (Gabbard et al., 2011).
Second, psychologists should proactively set controls that limit who sees their personal information. Several sources recommend that practitioners set security levels on social networking sites as high as possible (American Medical Association, 2010; Lehavot et al., 2010; Myers et al., 2012; Taylor et al., 2010), allowing for friend-only access (Barnett, 2008). It's important to acknowledge that for many people, it's not always easy to adjust privacy settings. For example, on Facebook, adjusting privacy levels may include separate settings for wall posts, photos, applications and social advertisements (Lee, 2009).
Psychologists may also consider using an online pseudonym to make it difficult for clients to locate their personal information (Barnett, 2008; Taylor et al., 2010). Yet even pseudonyms are not failsafe, since some posts may be traceable to a user's email or IP address.
Practitioners who are uncertain of their technological competence on social media should consult with colleagues who are knowledgeable about the technology (Barnett, 2008; Taylor et al., 2010) and compile resources.
Reducing liability risk online
Although social networking sites are popular ways to form and maintain social relationships, psychologists who use them are at greater risk of causing harm. For example, intentional or inadvertent disclosure of confidential information on social media could pose ethics violations and lead to legal problems under the Health Insurance Portability and Accountability Act, the Health Information Technology for Economic and Clinical Health Act and state law (Wheeler, 2011).
To limit the liability risk of using social media, practitioners may need to take certain precautions. First, they should contact both their professional and personal liability insurance representatives to find out whether their professional and personal liability insurance covers social networking sites. Along these lines, it would be helpful for APA to provide more nuanced guidelines regarding two aspects of social media communication: First, what online activities may or may not be considered part of a client's record (Martin, 2010), and second, what online activities are considered acts of a multiple relationship versus incidental contact (Sonne, 1994).
Second, psychologists should avoid using certain types of speech online, even if they use high privacy restrictions and other protections, such as pseudonyms. These communications might include breaches of client or supervisee confidentiality, speech that is potentially libelous and speech that denigrates the reputation of psychology. For example, practitioners should not post client information, disparaging comments about colleagues or client groups, unprofessional media (including photographs and/or videos that undercut the reputation of psychological practice), and comments about litigation in which one is involved (Gabbard et al., 2011).
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