Ethical gray areas, trolls, and more: Ways to create trustworthy social media content

Ashley Elliottopens in new window, PsyD, stands in her Washington, DC, kitchen, rainbow mug in hand, and hits “record” on her camera phone. “Good morning! I hope you have a great day on purpose,” she tells her 80,000 TikTok followers. “Remember that you are not an octopus, so there are certain things that are just going to have to wait for later. But what shouldn’t wait for later is you checking in on yourself.”

Known online as Dr. Vivid, a reference to her consulting company, Elliott posts comments that can be empowering, quirky, vulnerable, and occasionally curse-laden. She is not afraid to dance about getting her psychotropic meds refilled or, in one regular segment, riff on some of the things she has said to (unidentifiable) therapy patients to demystify what sessions can actually be like.

Her mission: To combine psychoeducation, humor, and relatability to reduce stigma and fear around mental health conversations, especially with people who might not have access to therapy or realize that therapists like her—a Black, queer, neurodivergent single mom—even exist. “Every clinician isn’t a sterile person in an armchair with their notepad,” said Elliott, who has a private practice in Arlington, Virginia, and co-led a workshop at APA 2023 about creating ethical content in digital spaces.

She knows she is making an impact. After posting one early Instagram video about how it is “OK not to be OK,” Elliott received a message from a woman who said the post prevented her planned suicide that night. “I had an aha moment: If this person said they can go on for another moment, another day, I have to keep doing this,” said Elliott, who is also a workshop consultant for Take This,opens in new window a mental health nonprofit that serves the gaming community.

Elliott is among a growing group of psychologists working to reach people where they are: on social media and gaming platforms like TikTok, YouTube, and Twitch. Doing so ethically means ensuring the content is rooted in scientific and professional knowledge, as well as considering how any content could affect viewers and patients, said Lindsay Childress-Beatty, JD, PhD, APA’s chief of ethics. “Once identified as a psychologist, creators are representing the profession and what they say reflects on psychology,” Childress-Beatty added.

But not all mental health professionals with big social media platforms are meeting that bar. Some deliver what could be considered therapy in a nonconfidential way, present themselves as an expert beyond the scope of their training, or spread outdated or flat-out wrong information about mental health. Plenty of creators with no mental health training do the same thing.

That is all the more reason for psychologists to responsibly enter the fray, said Ali Mattuopens in new window, PhD, a clinical psychologist in San Francisco whose YouTube channel, @DrAli, demystifies mental health conditions, debunks psychological misinformation, and demonstrates coping mechanisms.

“Think about our students, our patients, everyone we’re working with—the content they’re seeing is the content that’s been created. And if our voice as psychologists is not there in that content, then where else are these people going to go?” he said. “If we are not a part of the conversation, the conversation continues without us.”

[Related: Tips for starting, or growing, an ethical social media presence]

There is no question that saturating online spaces with psychologists is critical for APA’s very mission: to promote the advancement, communication, and application of psychological science and knowledge to benefit society and people’s lives.

“These communication tools provide opportunities for educating the public about behavioral health and psychological services as well as broader interrelated health issues,” APA’s social media policy (PDF, 662KB)opens in new window states. “They can also be very useful for reaching individuals from underserved populations, disabled individuals without access to transportation, and those living in remote areas.”

Indeed, less than half of Americans with a mental illness receive treatmentopens in new window, and chances are they are online. According to the Pew Research Center, about 90% of the North American population has used the internet, and 80% of internet visitors use it to seek out health information.

“People will always seek support, and if the medical establishment can’t provide it, they’re going to find another space,” said Kelli Dunlapopens in new window, PsyD, a clinical psychologist and game designer in Whitesboro, New York, who co-led the convention session with Elliott and serves as the director of community at Take This. “And for many folks, those communities are online.”

Gaming platforms in particular can be a key but often overlooked place for psychologists to reach people, said Dunlap, a lifelong gamer herself. Some data suggest 76% of under-18-year-olds play video games in the United Statesopens in new window, and 67% of American adults do.

“Games are a big way kids and teens and 20-somethings get their social needs met or fulfill basic needs around autonomy and competence,” Dunlap said. “In an age where we’re so isolated and separated and lonely, games are such a wonderful space where people can connect.”

Another potential benefit of engaging the public online: It can support your clinical practice in various ways.

For Dunlap, speaking the same language as her emerging adult patients strengthens their bond and accelerates their work. “The way their faces light up when I say, ‘You don’t have to explain Discord to me’ or ‘I know what PAX is’—the relief they feel not only is rapport-building, but it gives them that validation of feeling seen and heard.”

Justin Puderopens in new window, PhD, a clinical psychologist in Boca Raton, Florida, known as @amoderntherapist on TikTok and Instagram, also finds his daily videos, which aim to crush mental health stigma through humor, attract patients who get him—and vice versa. He said 100% of his caseload is people who have scheduled sessions only after finding and resonating with his videos online.

“When I worked in systems, I had patients who were a bad fit for me all the time,” said Puder, who has 684,000 followers on TikTok. “I haven’t had a bad client fit for me since I started this. They can make an informed decision off the jump.”

For Ryan Earlopens in new window, PhD, a licensed marriage and family therapist in Las Vegas, gaming platforms offer the chance to interact with a broader range of people and psychological concepts.

“The stream provides this real diversity of things that come up for people—they’ll ask about concepts my in-office patients aren’t talking about,” said Earl, whose 18,500 Twitch followers know him as Dr. Mick. “So I see the two aspects of my career as working together.”

Naturally, there are drawbacks to having an online presence. For Elliott, they have been severe. She has been called a groomer, a pedophile, and a puppet. She has received death threats, and even had to move to protect her kids’ safety after being doxxed.

“That’s been really difficult, but luckily I knew what I was up against, and I know that if I back out, they win, and the people who need this information lose,” she said.

Building and maintaining a robust following is also hard work, with unreliable monetary rewards. While creators can make money through brand partnerships, subscriptions, advertising dollars, and merchandise, psychologists’ ability to do so ethically is limited. “Just like it would be unethical to sell merchandise to patients in their waiting room, they need to consider if any commercial aspects fit ethically with their clinical practice with patients,” Childress-Beatty said. Plus, Earl said, most of any revenue earned through online content goes back into supplies, such as camera equipment.

Success online also takes more than posting a few nice quotes here and there. “Do not think you will become a wildly successful influencer if all you’re doing is what a billboard could do,” Dunlap said.

Rather, authenticity is key, said Mattu, who has 280,000 YouTube subscribers. “What keeps audiences coming back and keeps them listening is feeling like you are an authentic, trustworthy person,” he said. “And it can take years to get to a place where you are creating something authentic.”

On a daily basis, it takes hours. Puder, for one, blocks out about 20 hours a week on his calendar to write scripts, scroll TikTok for trending themes, and film. “To grow your social media presence, you have to post every single day,” he said.

That can lead to burnout. In fact, one report found that 90% of content creators have experienced burnoutopens in new window, and 71% have considered quitting social media altogether. To protect against burnout, Puder takes some breaks in slower months, like over the summer, and makes up for it during more critical times, like mental health awareness month. “I learned the hard way,” he said.

Earl also learned that his original playbook was unsustainable. When he was working as a professor and seeing patients, he would livestream from 11:30 p.m. to 1 or 2 a.m. and sleep for 4 hours. Now that he has left academia and has the flexibility of running his own private practice, “streaming does not burn me out because I enjoy doing it—I consider it a part of my self-care,” he said.

APA’s code of ethics and social media policy outline ground rules such as only sharing evidence-based information, being up front about what your credentials do and do not mean to followers, making clear that followers are not your patients, and keeping any patient information confidential.

But given the fast-changing nature of internet platforms, a social media policy cannot walk psychologists through every possible ethically murky scenario. That is up to the creators themselves.

“If you know what your code of ethics is and you set boundaries and you take it seriously, it’s not hard,” said Earl, whose near-nightly streams involve answering general mental health questions and gaming while providing psychological commentary on characters’ choices and relationships. “Where it gets hard is when creators push up against those boundaries—usually subconsciously—and then doing so gets reinforced” with more followers and, often, financial rewards, he added.

For example, some therapists publicly provide followers with what could be considered therapy, but without protections like intake agreements. They may try to get away with it—or earnestly believe they are remaining ethical—by calling the interactions “conversations,” Earl said.

“People create their own ethical minefields when they start to reconsider, ‘well, people will watch this’ or ‘well, people will benefit from watching this.’ And I have no doubt that people would benefit. But at what cost?” said Earl, who has turned down many requests to livestream a therapy session. “My channel could be way bigger if I were unethical. I’m willing to take that hit to do it the right way.”