Technology and Psychology Professionals
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ASnapshotofChildPsychologistsSocialMediaActivity.pdf
A Snapshot of Child Psychologists’ Social Media Activity: Professional and Ethical Practice Implications and Recommendations
Rachel A. Tunick, Lauren Mednick, and Caitlin Conroy Children’s Hospital Boston, Boston, Massachusetts and Harvard Medical School
In the face of the ever-growing popularity of social media, psychologists continually encounter new dilemmas regarding our ethical and professional principles. Negotiating the balance between the intrinsically public nature of social media participation and the highly private nature of the therapeutic relationship can be a challenge. Psychologists working with children and adolescents are of particular interest, given both the popularity of social media among children and teens and the specific treatment concerns on which clinical work often focuses. The authors surveyed 246 psychologists and psychologists-in-training regarding their own blogging and social networking practices, as well as their behavior around their clients’ online presence. A majority of respondents indicated that they participate in some form of social media and a lesser, though sizable, percentage reported viewing information about their clients online. Many respondents indicated that they have encountered concerning material on their clients’ social media pages, and there does not appear to be a clear consensus about how psychologists handle matters of Internet safety and privacy with their underage clients. Based on the responses to this survey, a series of considerations and guidelines for our professional practice are proposed, and psychologists are encouraged to engage in thoughtful self-reflection as they establish their own policies regarding these matters.
Keywords: Internet, ethics, social networks, blogs, children and adolescents
It’s 10:00 on a Friday night. A child psychologist sits at her home computer checking Facebook updates and thinking about upcoming weekend plans. Distracted by thoughts about a par-
ticularly intense session that afternoon with a teenage client, wherein he’d disclosed some distressing recent peer interac- tions, she decides on a whim to try to view his Facebook page. She finds it easily, set up without privacy restrictions, and is troubled when she reads his latest status update: “I’m going to sleep now . . . See you all on the other side.” The psychologist continues to read back through her client’s Facebook wall and is horrified to find a series of taunting and harsh comments left by some of the client’s “friends” over the past few weeks. After viewing this disturbing content for a short while, the clinician feels uncertain about her professional obligation and worriedly wonders what she should do to help ensure her client’s safety.
In today’s Internet age such a scenario, in which psycholo- gists may readily gain access to client information outside of session, is becoming increasingly commonplace. Similarly, our clients can obtain online access to our personal information via a simple click of the mouse. This bidirectional flow of easily accessible personal information regarding clients and clinicians alike has the potential to lead to momentous changes in our professional relationships and behavior. The widespread use of social media, including social networking sites and blogs, has led to dramatic changes in interpersonal communication in our society as a whole. For psychologists, these changes raise dilemmas regarding our ethical and professional principles, particularly those pertaining to self-disclosure, informed con- sent, and confidentiality. Moreover, for clinicians working with children and adolescents, unique dilemmas exist concerning the protection and safety of our clients and how to define the limits of our responsibility to protect their welfare.
This article was published Online First October 31, 2011. Editor’s Note. This is one of 19 accepted articles received in response to an open call for submissions on Telehealth and Technology Innovations in Professional Psychology.—MCR
RACHEL A. TUNICK received her PhD in child clinical psychology from the University of Denver, with a specialization in developmental cognitive neuroscience. She is a staff psychologist on the inpatient Psychiatry Con- sultation Service at Children’s Hospital Boston and maintains an academic appointment in the Department of Psychiatry at Harvard Medical School. Her research and professional practice focus on various cognitive, psycho- logical, and ethical issues impacting patients, families, and care providers in the pediatric medical setting. LAUREN MEDNICK received her PhD in clinical psychology from The George Washington University. She is on staff at Children’s Hospital Boston, with an appointment at Harvard Medical School. Her clinical work and research focus on helping children and adolescents cope with a variety of chronic and acute medical conditions. CAITLIN CONROY received her PsyD in clinical psychology from the Mas- sachusetts School of Professional Psychology. She is a staff psychologist at Children’s Hospital Boston, working in the Mayo Family Pediatric Pain Rehabilitation Center in Waltham, MA. Her areas of professional interest include clinical pediatric psychology, pediatric pain treatment and out- comes research, and family factors in pediatric pain rehabilitation. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Rachel A. Tunick, Children’s Hospital Boston, 300 Longwood Avenue, Main 8 South, Boston, MA 02115. E-mail: [email protected]
Professional Psychology: Research and Practice © 2011 American Psychological Association 2011, Vol. 42, No. 6, 440 – 447 0735-7028/11/$12.00 DOI: 10.1037/a0025040
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The Age of the Internet and the Advent of E-Professionalism
The past several years have seen substantial growth in the prevalence and use of social media, including blogs and social networking sites (BSNs), and it appears that the popularity of such media will only continue to heighten. A recent survey of social media use indicated that about 10% of adults and 14% of adoles- cents maintain a personal online journal or blog, while 47% of adults and 73% of adolescents reported participating in social networking sites (Lenhart, Purcell, Smith, & Zickuhr, 2010). Ac- cording to that survey, the most commonly used social networking site is Facebook, with more than 500 million users as of June 2011 (Facebook, 2011).
In the face of this continually expanding phenomenon, there has been recent increased focus on the intersection of online behavior and professional practice across a range of settings and occupa- tions. For example, several recent studies have examined social networking practices of physicians and doctors-in-training (e.g., MacDonald, Sohn, & Ellis, 2010; Moubarak, Guiot, Benhamou, Benhamou, & Hariri, 2010; Thompson et al., 2008; Garner & O’Sullivan, 2010). These studies found that many such profession- als participate in social media, allow their user profiles to be accessible to the public, and display potentially unprofessional material (e.g., photographs of the users drinking alcohol, intoxi- cated, or in various states of undress; discussion of clinical expe- riences with clients; membership in groups with off-color or pro- fane names) on their sites. Such findings have led to the coining of the term “e-professionalism” to describe a new facet of profes- sionalism pertaining to online behavior and communication and have prompted discussions regarding the need for guidelines around the application of professional and ethical principles in the digital era (Cain, 2008; MacDonald, Sohn, & Ellis, 2010).
Within our own profession, we subscribe to a set of ethical standards and expectations for interacting with clients in a manner that will not cause harm and which will be in their best interest (American Psychological Association [APA], 2002). Although our ethics code does not directly include professional guidelines spe- cific to online behavior, the principles behind these standards can be applied to situations involving social media. For example, while our ethics code does not discuss interacting with clients via social networking, it explicitly advises against engaging in multiple re- lationships with clients when there exists the potential to cause the client harm or to compromise the effectiveness of therapy (Taylor, McMinn, Bufford, & Chang, 2010; Zur, Williams, Lehavot, & Knapp, 2009). If an online relationship allows a client with poor boundaries an opportunity to gain access to personal information about their clinician, this can be construed as a dual relationship, which has the likelihood to negatively impact the effectiveness of therapy, and would be discouraged by our code of ethics. How- ever, the “potentially ambiguous nature of the types of interac- tions” that occur via online communication and lack of clarity regarding the distinction between professional and personal make it difficult to know how to apply the APA ethics code (Lehavot, Barnett, & Powers, 2010). Such ambiguity leaves us vulnerable to experience a host of ethical and professional dilemmas. The pre- dicaments encountered by clinicians working with children and adolescents are of particular interest, given the growing popularity
of BSN activity among youth and the vulnerability of this popu- lation.
Ethical and Professional Dilemmas in the Digital Age
For psychologists who work with children and adolescents, ethical and professional dilemmas may occur in the context of two types of online behavior. First, predicaments may arise around the BSN practices of clinicians themselves. In particular, such behav- ior may open the doors to unintentional therapist self-disclosure, which may threaten professional boundaries and, by extension, the effectiveness of our treatment. Second, dilemmas may arise in the context of the Internet behavior of our clients, particularly when we choose to view this online content outside of our clients’ presence or permission (a practice that is, in and of itself, ethically questionable). In such circumstances we may find ourselves privy to information about our clients that we might not have known otherwise, and this may lead to uncertainty regarding appropriate follow-up actions.
Dilemmas Associated With Psychologists’ BSN Practices
When psychologists maintain BSN sites, ethical and profes- sional dilemmas may arise regarding client-therapist boundaries. In particular, when clients can access online information about their therapist, this may lead to irreversible changes in the nature of the clinical relationship. An extensive body of literature sup- ports the preservation of boundaries between clients and therapists, for reasons including the promotion of transference (e.g., Luo, 2009), avoidance of exploitation, and maintenance of therapeutic focus on issues relevant to the client (e.g., Taylor et al., 2010). Psychologists vary in their views around therapist self-disclosure, depending on factors such as their theoretical orientation, culture, and style. Many feel that circumstances exist in which some form of therapist self-disclosure may be beneficial (e.g., for the en- hancement of therapeutic alliance; Zur et al., 2009) and that at other times self-disclosure is contraindicated (e.g., when a client has particularly poor boundaries; Taylor et al., 2010). However, it is generally agreed upon that thoughtfulness and intentionality are essential in the handling of issues of self-disclosure (Taylor et al., 2010), and that when self-disclosure is used it should contain a clinical rationale focused on the client’s best interest (e.g., Zur et al., 2009).
The advent and continued expansion of BSNs in our daily lives has “redefined the meaning and application of self-disclosure and transparency in psychotherapy” (Zur et al., 2009), particularly when clinicians themselves are active social media participants. When clients gain access to online material about their therapist, they may learn personal information (regarding, e.g., the thera- pist’s religious, political, or moral beliefs, hobbies, family and social life, etc.) that may compromise professional boundaries. In the Age of the Internet, it is increasingly difficult for psychologists to approach self-disclosure with the thoughtfulness and intention- ality that is so crucial in other contexts, and we may be faced with unfiltered, inadvertent self-disclosure by virtue of our own online behaviors (Taylor et al., 2010).
Two recent surveys have examined BSN behaviors among psy- chologists and psychology trainees in the United States, with
441SPECIAL ISSUE: SOCIAL MEDIA AND PROFESSIONAL PRACTICE
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particular focus on issues related to self-disclosure and boundaries (Lehavot et al., 2010; Taylor et al., 2010). Both surveys, conducted primarily with psychology graduate students (100% and 91% of survey respondents, respectively; Lehavot et al., 2010; Taylor et al., 2010), revealed that the majority of respondents participate in online social networking (77% and 81%), with 15– 40% choosing not to implement strict privacy settings. Lehavot and colleagues (2010) further report that 67% of respondents use their real name, 29% post photos, and 37% include personal information which they would not want their clients to see. Taylor et al. (2010) conclude that unintentional disclosure is inevitable with the ease of access permitted with the Internet and advise psychologists to strive to exercise some control over the amount and type of personal information to which clients may gain access by not participating on social networking sites or by using high privacy settings.
Dilemmas Associated with Clients’ BSN Practices
A range of ethical and professional dilemmas may also arise in the context of the online activity of our clients, particularly when we view such content without the clients’ presence or knowledge. The motivation of clinicians engaging in such behavior is of particular interest. One of the surveys reviewed above (Lehavot et al., 2010) examined clinicians’ behavior with regard to their cli- ents’ online activity and found that 27% of respondents sought information about clients online, with many reporting to do so out of curiosity or to “establish the truth.” The authors argue that searching for information for these reasons is unethical, as it involves obtaining information about the client without consent. In addition, such behavior violates our ethical principles of benefi- cence and nonmalficence (i.e., taking care to do no harm to clients and the therapeutic process) and fidelity and responsibility (creat- ing and maintaining a trusting relationship with clients).
Tunick and Mednick (2009) raised discussion about additional dilemmas that may arise in the context of patient BSN activity in the pediatric setting and reviewed four categories of such dilem- mas. These include threats to 1) privacy/confidentiality of other patients whose protected health information may be referenced on clients’ BSN sites without their consent; 2) professional reputa- tions of clinicians who may be named on patient BSNs, particu- larly if the content is at all negative or disparaging; 3) privacy/ confidentiality of clients who do not fully appreciate implications around the potentially very public nature of their site’s content; and 4) professional boundaries, when clinically significant infor- mation is obtained by the clinician without the client’s knowledge or consent. Across these categories, when psychologists view such material on their client’s sites, their subsequent professional obli- gations and course of follow-up action is unclear (Tunick & Mednick, 2009; Zur, 2010).
With the goal of gleaning information to inform and guide our professional practice, we undertook a national survey of child clinical and pediatric psychologists regarding their own online practices as well as their behavior around the BSN activity of their clients. Many of the ethical and professional dilemmas outlined above are particularly salient for those working with youth, given the popularity of social media use among children and adolescents, and the vulnerability of this population as a whole. However, to
our knowledge no such study has been undertaken with child clinicians.
Survey of Psychologists’ Online Practices
The survey was conducted via completion of anonymous online questionnaires about psychologists’ own BSN practices and their experiences around reading the BSNs of clients. The survey was divided into four sections. The first section, completed by all respondents, included 15 questions regarding demographics, pro- fessional training, current employment setting/population, and ex- periences regarding client BSN privacy and safety (e.g., “Have you ever encountered a situation in which you became concerned about the privacy of your client, related to their use of a blog/social networking page?”). Participants were directed to complete the remaining three sections of the survey depending on whether they have a blog, participate as a member of a social networking site, and/or read the BSNs of their clients. Ten questions (yes/no, multiple choice, and Likert scale formats) were included in each of these three sections, and many of the questions also prompted open-ended responses.
Child and pediatric psychologists and psychologists-in-training were recruited via online listservs for APA Divisions 53 (Child Clinical Psychology) and 54 (Pediatric Psychology). In total, 246 participants, 83% of whom had attained a doctoral level degree, completed the survey. At the time the survey was conducted, there were 1627 members on the Division 53 listserv, and 1103 people registered on the Division 54 listserv. It was not possible to obtain an estimate of the degree of overlap between these two samples, although it was expected that a sizable overlap did exist. Thus, a valid response rate could not be ascertained, and potential impli- cations of this study limitation are addressed in the final section of this paper. However, respondents appear to be representative of these groups, as in general the clinicians who completed the survey largely reflect the demographics of the two APA divisions (APA, 2009a, 2009b). Specifically, the majority of participants were female (79%), Caucasian (89%), and had an advanced degree in clinical psychology (86%). Respondents were employed across a variety of clinical/academic settings, and nearly all (99%) reported being involved in clinical work with children and/or adolescents. Of note, however, respondents to the survey were younger (M � 37.4 years) relative to the mean age of members of Divisions 53 and 54 (49.5 and 47.6 years, respectively).
Survey Results Regarding Psychologists’ BSN Practices
Sixty-five percent of respondents participate on social network- ing websites, whereas 9% maintain blogs. Compared with those who don’t participate on social networking sites, social-networkers are significantly younger, t(242) � 5.65, p � .001, more likely to be current students, �2(1) � 11.35, p � .01, and spend less of their time in activities related to teaching and supervision, t(204) � 2.10, p � .05. The most commonly used social networking site was Facebook (95%), followed by Linkedin (34%) and MySpace (16%). At the time of the survey, 56% of participants had been involved in social networking for one year or less, and most respondents (70%) check their site at least several times a week. The vast majority of social networking respondents reported im-
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plementing restrictions on who can view their page, nearly half reported having material on their page that they wouldn’t want clients to view, and a small percent reported knowledge of situa- tions in which a client gained access to their page (see Table 1). A significant relationship was not found between having restrictions on who can access their social networking page and including anything on your page that you would not want your clients to see (r � .06, p � .45); however, this is likely attributable to the majority of participants reporting using privacy restrictions.
About one-quarter of social networking respondents have been approached by clients to be “virtual friends,” and clinicians varied in their reported responses to such situations. The majority indi- cated that they had rejected the invitation, but some reported either having made different decisions “based on the situation” or having accepted a friend request (see Table 1). Similarly, when survey respondents were asked what they “might” do should they find themselves in this hypothetical situation, a small percent (7) re- ported that they would make different decisions “depending on the situation,” while the remainder indicated that they would reject the friend request.
Compared with those who don’t maintain blogs, bloggers were significantly more likely to work in residential, �2(1) � 8.33, p � .01 or community mental health settings, �2(1) � 6.13, p � .05, be younger, t(240) � 2.53, p � .05, and read client BSNs, �2(3) � 11.93, p � .01. The majority of bloggers have been blogging for more than one year (55%), and most (68%) reported that they check their blog at least once a week. The majority of bloggers reported using their real name on their blog, more than half do not implement any restrictions regarding blog access, and about one-
quarter said that there is information on their blog that they wouldn’t want clients to see (see Table 1). Importantly, there was a significant positive correlation between having restricted blog access and posting blog material that you would not want your clients to see (r � .47, p � .05).
Survey Results Regarding Clients’ BSN Practices
Thirty-two percent of respondents reported reading client BSNs for a variety of reasons, including curiosity (see Table 2). Simi- larly, 32% of respondents reported that they have “Googled” their clients. Among those who read client BSNs, more than half ask or inform clients of this practice. Less than half of respondents reported having encountered concerning material on client web- sites. Notably, this correlated strongly with addressing such con- cerns with clients (r � .57, p � .001). Among those who never read client BSNs, the majority report avoiding reading because of perceived boundary violations (see Table 2). Finally, only 35% of respondents reported addressing concerns about Internet privacy with their underage clients who participate in BSNs.
Responses to open-ended questions indicated that many clinicians have encountered “concerning” material on their clients’ BSNs. The most commonly described themes concerned information pertaining to substance use, sexual promiscuity, bullying, depressive thoughts, and suicidal ideation. Participants also described general concerns about children and adolescents implementing no privacy restrictions on their BSNs and revealing too much personal information about themselves, including inappropriate photographs. Further, many re-
Table 1 Responses From Those Who Participate in Social Media
n (%)
Social networking respondents Use a pseudonym 9 (6) Has restrictions on who can access their SN site 154 (98) Type of restrictions
Highest restrictions 141 (92) Medium restrictions 13 (8)
Have photos of yourself on your SN site 143 (90) Include personal information on your SN site 125 (79) Anything on your SN site you would not want your clients to see 69 (43) Learned that a client accessed your SN site 8 (5) Been asked to “friend” a client or join their network 38 (24) Response
Accepted the invitation 1 (3) Made different decision based on the situation 4 (10) Declined the invitation 33 (87)
Blogging respondents Use a pseudonym 8 (36) Has restrictions on who can access their blog� 10 (45) Type of restrictions
Highest restrictions 9 (90) Medium restrictions 1 (10)
Have photos of yourself on your blog 16 (73) Include personal information on your blog 17 (77) Anything on your blog you would not want your clients to see� 6 (27) Learned that a client accessed your blog 3 (14)
Note. n (social networking) � 159 (65); n (blogging) � 22 (9). � Strong relationship between having restrictions on access and having anything on the blog you would not want your client to see (r � .47, p � .05).
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spondents commented about the ambiguity of their professional role in the face of such concerns.
Clinical Implications and Recommendations
Given the widespread, growing use of electronic communication in today’s society, it is certain that our profession will continue to encounter online situations that challenge our ethical and profes- sional principles. Results from our survey suggest that a sizable proportion of child clinicians participate in BSNs, and many of our colleagues also read the BSNs of their clients. Overall, the major- ity of respondents appear to consider and adhere to professional and ethical principles regarding these practices. However, some findings suggest that further consideration should be given to standards pertaining to issues around privacy, informed consent, and professional boundaries. As such, survey results were used as a springboard to inform the considerations and guidelines dis- cussed below.
Considerations and Guidelines Regarding Psychologists’ BSN Practices
Consistent with two prior surveys conducted primarily with psychology trainees (Lehavot et al., 2010; Taylor et al., 2010), results from the current study suggest that the majority of child psychologists participate in social media. Although most partici- pants reported that they use high privacy settings and limit their online engagement with clients, there remain some who do not adhere to such standards. Further, we have reason to suspect that the proportion of users who report implementing the highest pri- vacy settings may be overstated, given that 24% of social- networkers have received “friend requests” by clients. In fact, if
the highest privacy settings (i.e., rendering oneself “unsearchable”) had been implemented, such requests would not be possible.
In the Internet age, our ethical considerations around profes- sional relationships and boundaries remain the same as always but are uniquely challenged when personal information regarding psy- chologists is readily available online to clients. BSN behavior has the potential to blur the lines between professional and personal domains, which may impact negatively upon the effectiveness of therapy by compromising our ability to approach self-disclosure with thoughtfulness and intentionality (Taylor et al., 2010). The most simple and straightforward way to avoid such dilemmas would be for psychologists to abstain altogether from participation in BSN activities. However, in the context of our society’s ever- growing reliance on the Internet and the pervasive use of social media, we recognize that such a unilateral stance is increasingly naı̈ve and unrealistic. Hence, the following considerations and guidelines are recommended.
Maintain Awareness
Clinicians must be aware of the potential dilemmas that may arise when participating in social media. We recognize that psy- chologists vary greatly in terms of their overall approach to self- disclosure, and such practices should remain consistent whether pertaining to in-person or virtual settings (Guseh, Brendel, & Brendel, 2009). Thus we encourage our colleagues to engage in thoughtful reflection regarding their own views, beliefs, and ratio- nale underlying the choices they make around self-disclosure in general, and be certain that this stance is reflected in their online behavior. Psychologists are further encouraged to consider the relative permanence of online content and potential interpersonal, professional, and/or legal ramifications that this might trigger (Landman, Shelton, Kauffmann, & Dattilo, 2010).
Table 2 Clinicians’ Responses About Their Practices Regarding Client BSN Activity
Item n (%)
Do you ever read the BSN sites of your clients? 78 (32) Among those who DO read client BSN sites
Main reason for reading Curiosity 14 (18) Therapeutic concern 32 (41) Request by a client or family 23 (29) Gather treatment-related information 7 (9) Other 2 (3)
Approach to reading Told the client you read the BSN site 16 (20) Asked the client for permission to read 31 (40) Depended on the situation 17 (22) Did not tell client or ask for permission 14 (18)
Read information on a client’s BSN that was concerning to you� 32 (42) Addressed concerns that have arisen from reading client BSN site� 24 (31) Read a client’s BSN site with a client 32 (41)
Among those who NEVER read client BSN sites Main reason for not reading
It has never come up 48 (29) It feels outside of therapeutic boundaries 104 (63) Other 14 (8)
� Strong relationship between read information on a BSN site that was concerning and addressed concerns (r � .57, p � .001).
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Be Savvy and Diligent About Privacy Settings
Social networking sites offer participants a range of privacy settings, which allows users to oversee and limit the overall audi- ence to whom features of their page are accessible. Similarly, many blog-hosting sites offer varying levels of privacy protection, which users may choose whether or not to employ. However, the particulars of these privacy settings are complex (Luo, 2009), and the maintenance of privacy settings is a continually moving target. For example, Facebook’s privacy policy is nearly 6000 words long, contains distinct privacy options for each site feature, and is regularly updated and changed (Facebook, 2010). Furthermore, across most BSN media, the default setting typically leans toward inclusion rather than exclusion. BSN users must remain vigilant to such nuances and to the continual changes relevant to the settings that they employ (McDonald et al., 2010) and recognize that without such diligence their personal material might become ac- cessible to viewers for whom it was not intended (Guseh et al., 2009). As for which privacy settings to implement, psychologists are advised to remain conscientious and choose settings in keeping with their aforementioned stance about the level of self-disclosure with which they are most comfortable.
Remain Transparent With Clients Regarding Your BSN Policy
If psychologists choose to actively participate in BSNs, we encourage them to maintain a proactive, rather than reactive, approach regarding potential online communication with clients. First, psychologists should carefully consider and develop a clear and consistent policy about their approach to online communica- tion with clients (Lehavot et al., 2010). Then, just as we routinely review with clients other professional policies (such as those regarding confidentiality and its limits), psychologists are encour- aged to be transparent regarding their online policy. This might include, for example, a clear in-person statement that you refrain from accepting “friend requests” from current or past clients, no matter the circumstances (Luo, 2009). In addition to engaging in such conversations at the start of treatment, psychologists are encouraged to engage in open dialogue with their clients in a timely manner, should relevant issues arise over the course of therapy.
Engage in Conversations with Trainees
Many of our survey’s respondents reported that they engage regularly in teaching and supervisory roles with trainees. As men- tors to future generations of psychologists, we encourage open and thoughtful discussion regarding BSN practices in the training context. In particular, psychologists might choose to review the aforementioned recommendations regarding online behavior. En- gaging trainees in such conversations is particularly important, given that in the current survey, younger respondents and those earlier in their careers reported higher rates of BSN participation. As noted by Lehavot et al. (2010), supervisees may well have more experience than their supervisors in the BSN domain, and thus clinical supervisors may need to educate themselves about these practices.
Considerations and Guidelines Regarding Clients’ BSN Practices
Findings from the current survey suggest that child psycholo- gists’ behavior regarding client online information is quite vari- able. About one third of participating clinicians reported viewing their clients’ online information without obtaining permission to do so. Nearly half of the respondents who read clients’ BSNs have encountered concerning situations on their clients’ sites, and re- spondents described a range of themes about which they had concern. About one third of respondents have addressed concerns regarding online privacy with their clients.
It is clear that viewing our clients’ BSN sites without their expressed permission opens the door to many potential dilemmas for psychologists. Such behavior exposes us to the risk of viewing content that ranges from somewhat concerning (e.g., a teenage client’s references to his experimentation with alcohol) to down- right alarming (e.g., explicit suicidal ideation on a client’s BSN) and which demands follow-up action of one type or another. When such material is encountered in-session with our clients, our ethical obligations and professional responsibilities are quite clear. How- ever, in the case that such content is viewed online and outside of direct patient contact, our appropriate follow-up course is more ambiguous (Tunick & Mednick, 2009). This concern is well artic- ulated by a survey respondent: “My primary concern with client information that is discovered on the Internet is, what is my responsibility if I do find something concerning? Am I mandated to report blog information? Can I raise that with the cli- ent? . . . Further, I think clinicians who read (client) blogs put the field at risk by setting a precedent that we ought to be responsible for that information. If we give people the idea that they can put things on their blogs and we will read it with the intent to intervene, what happens when they put a suicide note up at 2:30 a.m. and we do not see it?”
Furthermore, viewing online material about our clients with- out their knowledge or expressed permission (i.e., without their informed consent) infringes on our clients’ privacy, which violates principles of our ethics code. Simply because so much information is now readily available and easily searchable online, this does not mean that obtaining information about our clients without their permission is ethically acceptable behav- ior. Doing so violates a client’s autonomy and has the potential to disrupt the element of trust that is essential in a therapeutic relationship. As expressed by a survey respondent: “I feel it could jeopardize my therapeutic relationship with my clients if I gained information from a Google search or social networking site as opposed to acquiring that information directly from my patient or a person with whom I have authorization to commu- nicate (another doctor, family member).” Moreover, if material encountered online is discrepant from information learned in- session, how does one resolve this matter with a client who is unaware that the clinician is viewing their BSN site?
Of note, however, it might be argued that under certain circumstances there are compelling reasons for child clinicians to view their clients’ online material. For example, as indicated by many of our survey respondents, clients or parents may invite our readership, which may be beneficial for information sharing and alliance building. In addition, important concerns might not come to our attention were it not for reading a
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patient’s BSN. For example, a psychologist who learns about her patient’s drug use from material within his MySpace entries may confront the patient about this activity and follow up with interventions as warranted.
These matters concerning psychologists’ behavior around their clients’ online practices are certainly not straightforward. With regard to these issues we propose the following considerations and guidelines.
Weigh the Risks and Benefits
When we find ourselves in the position wherein we are consid- ering viewing our clients’ online material, we urge psychologists to engage in a thoughtful risk-benefit analysis. Clinicians are encouraged to carefully examine their own motivation for reading (Hughes, 2009; Luo, 2009). Are there potential benefits to be gained, from a clinical perspective? Might we learn information, not readily available otherwise, that will help us to promote the safety and well-being of our clients? Or are we primarily moti- vated by a prurient curiosity? What are the anticipated or potential risks for harm if we choose to view, or if we choose to not view? As one survey respondent wrote, “Ultimately, if my behavior with my client does not serve their clinical best interest I am violating their relationship to satisfy my curiosity.” Such careful contem- plation may help guide psychologists’ ethical decision making.
Read Together
Should psychologists decide that the benefits of viewing client information online outweigh the risks, we encourage our col- leagues to be transparent about this practice. Talk with your clients and their families about your motivation, and, prior to viewing, request their permission to access their website. Alternatively, as suggested by Lehavot et al. (2010), we propose that clinicians consider reading client BSNs together with their clients. Such a collaborative process may allow clinicians to gain new information and insight about their client, while also potentially benefiting the therapeutic process. This practice was supported by a survey respondent: “I work with teens who often put much more infor- mation in a public domain than is sometimes safe for them. However, these situations often open lines of therapeutic commu- nication because I usually view these pages WITH my patients rather than on my own.”
Educate Youth About Internet Risks
Many of our survey respondents reported having viewed con- cerning material on their clients’ BSN sites, and such concerns seem particularly salient for psychologists working with children and adolescents. In today’s society we often encounter situations that remind us of potential perils associated with online activity, such as news stories highlighting deleterious effects of cyber- bullying. As clinicians working with underage clients, our role is often construed to include a responsibility to help educate and monitor clients for their involvement in concerning or dangerous behaviors. Does this responsibility extend into the online context? In our view, engaging in risky behavior in the “virtual world” is no different than in any other contexts, and failure to recognize, monitor, and discuss these potentially dangerous behaviors is
inconsistent with our ethical obligations to protect our clients from harm (Lehavot et al., 2010). Children and adolescents are a vul- nerable population and may minimize or not fully grasp the po- tential dangers associated with involvement in BSN’s, and it is our obligation to help educate and protect them. This view was ex- pressed by a survey respondent: “I find myself often in dialogue with young adolescents about their perceptions about visibility/ privacy and consider the issue of the enduring nature of Internet media to be an issue that most cannot appreciate when posting to these sites.”
Despite these concerns, there are potential benefits when chil- dren and adolescents participate in social media. For example, Tynes (2008) suggests that social media participation can promote learning and have positive psychosocial benefits (e.g., increasing social support, fostering identity exploration, and building auton- omy). Rather than attempting to ban Internet activity, we encour- age child psychologists to promote safe Internet behavior with their clients. Psychologists should maintain open and honest dia- logue regarding the potential risks and benefits of Internet use and help young clients to develop an “exit strategy” should they find themselves in a concerning online situation (Tynes, 2008). This is particularly important for those working with clients whom they perceive as more vulnerable or naı̈ve. As expressed by one survey respondent, “I am concerned about the judgment of some of the younger patients, as well as some of my patients with impulsivity or social skills issues. They are at risk.”
Provide Guidance to Parents
Child psychologists regularly provide guidance and psychoedu- cation to parents and other caretakers regarding challenging situ- ations with their children. In a similar vein, we recommend that clinicians working with youth engage in dialogue with parents about matters pertaining to their children’s Internet safety. In these discussions, parents might be encouraged to actively monitor their child’s online activity. For example, if their child participates on Facebook, parents may choose to “friend” their child or periodi- cally ask their child to sign in with them so that they may collaboratively view the child’s page.
Conclusions and Future Directions
For better and for worse, the world is a changed place in the age of the Internet, and psychologists are certainly not immune to these influences. The current survey offers a preliminary snapshot of the overlap between social media and professional psychology prac- tice. In the current context, the roles and responsibilities of child psychologists remain largely the same. However, we are faced with newfound challenges regarding the application of our ethical principles in the context of online behavior and the dynamic Internet setting.
Informed by survey results, we have proposed several guidelines for our colleagues to consider in the face of the ethical and professional challenges that the Internet in general, and social media in particular, have prompted. We hope that our survey findings and resultant recommendations will stimulate some thoughtful self-reflection, as well as dialogue among our col- leagues, and will ultimately encourage continued deliberateness and thoughtfulness in our approach to these ever-changing phe-
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nomena. However, caution should be taken in interpreting the specific results of our survey, given that a precise response rate could not be calculated. Although demographic characteristics of survey respondents mostly mapped onto those of the APA Divi- sions from which they were sampled, there remains the possibility that there was a response bias, such that individuals who are more active online were more likely to respond to the web-based survey. This potential bias is reflected in the mean age of the survey respondents being significantly younger than the mean age of the members of the two listservs. However, as our survey results suggest that younger clinicians are more actively involved in BSN practices relative to their older colleagues, it is likely that this is the group for whom the survey and subsequent recommendations are most relevant.
Future research may include exploration of the potential benefits of talking about online privacy with our underage clients. We have speculated that there exist potential therapeutic benefits to engag- ing in such dialogue with our clients, but this is based more on anecdotal experience than empirical findings.
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Received March 4, 2011 Revision received June 20, 2011
Accepted June 21, 2011 �
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