Setting Boundaries with Patients

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timer Asked: Dec 21st, 2018
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Prior to beginning work on this week’s discussion, please review Standard 3: Human Relations (Links to an external site.)Links to an external site. in the APA’s Ethical Principles of Psychologists and Code of Conduct. Please also read the Asay and Lal (2014) “Who’s Googled Whom? Trainees’ Internet and Online Social Networking Experiences, Behaviors, and Attitudes with Clients and Supervisors,” Harris and Robinson Kurpius (2014) “Social Networking and Professional Ethics: Client Searches, Informed Consent, and Disclosure,” and Taylor, McMinn, Bufford, and Chang (2010) “Psychologists’ Attitudes and Ethical Concerns Regarding the Use of Social Networking Web Sites” articles.

Prior to beginning work on this week’s discussion, please review Standard 3: Human Relations (Links to an external site.)Links to an external site. in the APA’s Ethical Principles of Psychologists and Code of Conduct. Please also read the Asay and Lal (2014) “Who’s Googled Whom? Trainees’ Internet and Online Social Networking Experiences, Behaviors, and Attitudes with Clients and Supervisors,” Harris and Robinson Kurpius (2014) “Social Networking and Professional Ethics: Client Searches, Informed Consent, and Disclosure,” and Taylor, McMinn, Bufford, and Chang (2010) “Psychologists’ Attitudes and Ethical Concerns Regarding the Use of Social Networking Web Sites” articles. For this discussion, you will examine ethical issues encountered by clinical and counseling psychologists in the digital age. Begin by reviewing the cases of Dr. Arnold and Dr. Washington listed below and selecting one of these ethical dilemmas for analysis. Case 1 Dr. Arnold is a clinical psychologist who specializes in child and adolescent issues. From time to time, she provides consultation on high lethality cases within the juvenile court system. Recently, she was referred a case involving a 15-year-old male who has a history of aggression, angry outburst, destructive behavior, and cyberstalking. Concerned for her safety and well-being, Dr. Arnold input the client’s name into a search engine, which yielded the client’s social network page. Dr. Arnold is uncertain whether or not to look at the client’s social network page. Case 2 Dr. Washington is a counseling psychologist who specializes in trauma and self-harming behavior. Recently, he received a “friend request” from a former client who he provided individual therapy to six months ago. Dr. Washington opted not to accept the “friend request,” but considered sending a private message to the client with the social networking policy from his informed consent. Dr. Washington is uncertain whether or not to send the private message to the client. In your initial post, assume the role of a colleague to the doctor named and analyze the ethical issues encountered in your chosen case. Given the situation described in the case study, recommend how your colleague should proceed. Provide support for your response by citing the required articles for this discussion. Consider the current and potential actions of your colleague and explain whether or not he or she is currently, or potentially will be, in violation of the APA’s Ethical Principles of Psychologists and Code of Conduct. Provide support for your explanation by citing Standard 3: Human Relations (Links to an external site.)Links to an external site. in the APA’s Ethical Principles of Psychologists and Code of Conduct. Explain how your colleague might avoid this type of ethical dilemma in the future. Describe what policy or policies you might put in place if you were your colleague. Guided Response: Review several of your colleagues’ posts and respond to at least two of your peers who chose a case study different from the one you selected by 11:59 p.m. on Day 7 of the week. You are encouraged to post your required replies earlier in the week to promote more meaningful interactive discourse in this discussion. In your responses, evaluate the recommendations suggested by your peer. State whether you agree or disagree with your peer’s recommendation to the doctor on how to proceed. Suggest other ethical implications your peer may not have considered in this case. What follow up questions might you ask your peer to aid in the ethical assessment of the case? In addition to the suggestions provided by your peer, what recommendations might you make to the doctor so that he or she might avoid these types of dilemmas in the future? What additions or changes might you make to the policy or policies suggested by your peer?
Professional Psychology: Research and Practice 2010, Vol. 41, No. 2, 153–159 © 2010 American Psychological Association 0735-7028/10/$12.00 DOI: 10.1037/a0017996 Psychologists’ Attitudes and Ethical Concerns Regarding the Use of Social Networking Web Sites Laura Taylor, Mark R. McMinn, Rodger K. Bufford, and Kelly B. T. Chang This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. George Fox University Most psychologists seek to control self-disclosures they make to patients, but the Internet’s rapid development and widespread use over the past decade have introduced new problems for psychologists trying to avoid inappropriate disclosures. A total of 695 psychology graduate students and psychologists were surveyed about their current use of social networking Web sites (SNWs), opinions regarding regulation of online activities by the American Psychological Association (APA), and interactions in clinical work as a result of online activities. Established psychologists seldom use SNWs and may lack the experience to provide relevant supervisory guidance. No consensus about the need for APA guidelines emerged. Historically, APA has not issued guidelines in technological areas of rapid change. Thus, graduate training and continuing education should address the ethics of SNWs. Keywords: social networking, MySpace, Facebook, self-disclosure, Internet glass of water, or could it be a precursor to sexual innuendo or flirtation? Whereas some professional practice behaviors are simple matters of adhering to well-defined practice standards, self-disclosure is a more difficult matter because practice standards are not highly prescriptive, and because both advantages and disadvantages abound when it comes to revealing personal information to clients. Not surprisingly, different psychologists come to different conclusions, but virtually all psychologists affirm the importance of being thoughtful and intentional about how they handle issues of selfdisclosure (Schwartz, 1993). Professional distance helps maintain safety for clients. Psychologists who fail to maintain personal boundaries can emotionally harm clients. Appropriate boundaries can aid in focusing therapeutic work on the issues of clients. Self-disclosures of an intimate nature by the psychotherapist can be especially damaging when a strong therapeutic relationship has not been previously established. There are many instances when self-disclosure is contraindicated, such as when clients have poor boundaries and when the psychotherapist is especially vulnerable to potential boundary violations because of life circumstances (Goldstein, 1994). Although there are many possible problems with psychotherapist self-disclosure, there are reasons it is used in some clinical situations when the content of and reasons for the disclosures are carefully considered (Bridges, 2001). For example, disclosures about how a psychotherapist experiences the therapeutic relationship are sometimes used to help the client see patterns that may occur in other relationships (Maroda, 1999). Appropriate disclosures may help psychotherapists improve therapeutic rapport with clients (Lundeen & Schuldt, 1989 ; Zur, 2009). These findings should not be used to justify indiscriminate self-disclosure in psychotherapy. Disclosures of psychotherapists’ countertransference feelings have been found to damage therapeutic relationships (Myers & Hayes, 2006). Psychotherapists must be thoughtful and cautious about the information they share with clients, as it seems that subtle differences in During an intake interview, a male client asks a female psychologist if she is married. Should the psychologist provide a direct answer, or would it be better to focus on the client’s feelings and motives in asking such a question? It would be a much simpler matter if the client were to ask the psychologist for sexual favors— the answer to such a question is no and is clearly mandated by ethics and practice standards. Similarly, it would be relatively simple if the client were to ask for a glass of water. The answer would be yes, supported by human civility, compassion, and common sense. But the question about a psychologist’s marital status is not a simple matter. Is this as innocuous as asking for a LAURA TAYLOR received a PsyD in clinical psychology from George Fox University. Her primary research interests are graduate education in clinical psychology and impacts of technology on clinical practice. MARK R. MCMINN received a PhD in clinical psychology from Vanderbilt University. He is currently a professor of psychology at George Fox University. His primary research interests pertain to spiritual and religious issues in psychotherapy. RODGER K. BUFFORD is professor of psychology and former chair in the Graduate School of Clinical Psychology at George Fox University. He earned his BA in psychology from The King’s College and master’s and doctoral degrees from the University of Illinois at Urbana–Champaign. Research interests include spiritual well-being, spiritual maturity, and spiritual practices; religious/spiritual concerns, interventions, and outcomes in psychotherapy; assessment of mental health treatment outcomes in managed care settings; and clinical supervision ethics, process, and outcomes. A licensed psychologist, he also practices part time at Western Psychological and Counseling Services in Tigard, OR. KELLY B. T. CHANG received a PhD in psychology: teaching, learning, and cognition from the University of Hawai’i at Manoa. She is currently an assistant professor of psychology at George Fox University. Her primary research interests include positive psychology, emotional intelligence, diversity, and resilience. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Laura Taylor, 3240 SW 180th Pl, Beaverton, OR 97006. E-mail: haydonla@ hotmail.com 153 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 154 TAYLOR, MCMINN, BUFFORD, AND CHANG clients and situations may determine whether an action is helpful versus harmful to the client. Zur proposed three different types of self-disclosures in a recent article: deliberate, unavoidable, and accidental disclosures. Deliberate disclosures are made intentionally. Unavoidable disclosures can be intentional or unintentional. They are disclosures made through the course of the psychotherapist participating in his or her normal daily activities. Accidental disclosures often involve unplanned encounters with clients in public places or other unintentional revelations of information (Zur, 2009). Although self-disclosure practices vary among psychotherapists, all psychologists weigh several factors, or ought to, when making decisions about self-disclosure. These factors include, but are not limited to, theoretical orientation, established research, and ethical guidelines of practice. The implications for the client of any self-disclosure made by the psychotherapist must always be considered to stay within the minimal ethical guidelines of benevolence and nonmalfeasance. Because of the potential consequences of these decisions, psychologists avoid self-disclosures of a haphazard or unintentional nature. At the same time, psychotherapists frequently disclose information to clients without the conscious intention to do so (Bridges, 2001; Ehrenberg, 1995). Information can be disclosed through the décor in psychologists’ offices, their styles of dress, the holidays they observe, their physical appearance, and many other subtle characteristics (Wilkinson & Gabbard, 1993). These are relatively innocuous examples, but unintentional disclosures can cause problems in psychotherapy if the disclosure involves something inappropriate according to professional boundaries, if it interferes with the treatment process, or if it damages the client’s view of the psychotherapist as a competent and trustworthy individual. The American Psychological Association’s (APA) “Ethical Principles of Psychologists and Code of Conduct” does not speak directly to self-disclosure. It does advise against multiple relationships with clients that could result in exploitation or harm to the client (APA, 2002, Section 3.05). Contact with clients via the Internet, whether intentional or not, can change the nature of a client–psychotherapist relationship. It is easy for a client to begin to view the psychotherapist as a friend rather than a hired professional or expert once the client has knowledge of the psychotherapist’s personal life. Koocher and Keith-Spiegel (1998) stated, “Careful consideration should be given prior to softening a strictly professional relationship” (p. 173). It is difficult to establish firm ethical standards around self-disclosure because different types of self-disclosure have different implications for the psychotherapy relationship (Hill & Knox, 2001; Peterson, 2002). Most psychologists agree that disclosures about current stressors, personal fantasies or dreams, and sexual or financial circumstances are almost never considered to be ethical or helpful (Gutheil & Gabbard, 1993). Information disclosed about a psychotherapist’s family, hobbies, life struggles, political opinions, and other topics might be perfectly appropriate if shared with friends, but this kind of information can be a cause of conflict and can blur boundaries within a therapeutic relationship. Given the rapid technological changes of the past several decades, for today’s psychologists, unintentional self-disclosure is not limited to the art on one’s office wall. A curious client may conduct an Internet search to discover any available information about a particular psychologist’s life. Self-disclosures that take place over the Internet could also be seen as what ethics experts sometimes describe as “small-world hazards” (Campbell & Gordon, 1993) or “everyday life hazards” (Zur, 2009). These disclosures are thought to be largely unavoidable and should be dealt with in a direct manner as soon as they are recognized. But when small-world hazards involve the very large world of the Internet, it is often difficult to know that any disclosure has been made; therefore, it is difficult to deal with the disclosure in a direct manner. Many psychotherapists maintain Web sites describing their professional activities and services. Other psychologists are featured on the Web sites of organizations for which they are employed. Some psychotherapists allow clients to contact them via e-mail, and a few are even conducting therapy over the Internet (Rosen & Weil, 1996). One of the primary ethical concerns regarding use of e-mail and other online communications in clinical psychology is privacy and confidentiality for the client (Jerome et al., 2000). Clients may believe that the Internet is secure or that their e-mails are confidential and private when this is not always the case. Because of these risks to confidentiality, informed consent before a client participates in such activities becomes extremely important. Numerous different social networking Web sites (SNWs) have become popular for entertainment and communication in recent years. Popular sites include MySpace, Flickr, YouTube, Facebook, Second Life, Classmates.com, Friendster, Twitter, and Yahoo! 360. A personal Web page on one of these sites can contain a wide array of personal information about the subject of the page, including names of family members, group and club memberships, or substance use behaviors. A subscriber can post almost any information he or she chooses, and anyone listed as a “friend” can also post information to someone’s Web page. This often means that potentially embarrassing stories, photographs, and information are posted to the site by someone other than the subject of the page. Some of the information typically featured on SNWs might be considered taboo for sharing within therapeutic relationships; however, clients can freely access the SNWs of anyone they choose unless the privacy settings prohibit access. Even if privacy settings do not allow visitors to view a psychologist’s SNW, anyone can send a “friend request” to the psychologist, asking to be accepted as a “friend.” If a client were to do this, then the psychologist is left with a difficult choice of ignoring or rejecting the friend request on the one hand or accepting the friend request and allowing the client access to the psychologist’s personal information on the other hand. It is not clear how psychologists currently use SNWs, and how they handle the issues of self-disclosure that naturally arise for those who subscribe to SNWs. To gain information about psychologists’ and psychology graduate students’ behavior, we conducted a national survey. Social Networking Survey Students enrolled in doctoral-level psychology training programs and currently licensed psychologists were contacted through e-mail and asked to complete an online questionnaire. The names and e-mail addresses of potential participants were obtained through two different means. First, psychologists’ names were obtained through the online membership directory of the APA. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. SOCIAL NETWORKING WEB SITES Through random selection, 400 APA members’ names and e-mail addresses were obtained. Of these 400 e-mail addresses, 358 were still active or able to receive the message. Second, we contacted 205 training directors and faculty from selected APA-accredited doctoral programs in clinical and counseling psychology and requested that a link to the survey and an e-mail explaining the study be forwarded to students. In total, 929 individuals visited the site, and 695 participants completed the survey. Because of the snowball sampling method used, it is impossible to know the exact response rate, but the completion rate of 67% was respectable. Of the 695 participants, 114 (16%) were men and 580 (84%) were women. One participant declined to report a gender. With respect to ethnicity, 562 (81%) identified themselves as European American, 25 (4%) as Latino American, 24 (4%) as African American, 19 (2%) as Asian American, 18 (2%) as multiracial, 4 (1%) as Native American, 35 (5%) as other, and 8 (1%) did not report ethnicity. The mean age of participants was 29 years (SD ⫽ 7.6). The ages of participants ranged from 22 to 79 years. The majority of participants (55%) reported their highest degree to be a master’s degree, 31% a bachelor’s degree, 9% a PhD, 3% a PsyD, and 2% had earned another degree. Only 63 (9%) participants were licensed psychologists, indicating that the majority of the sample (632 or 91%) comprised graduate students. An additional 36 respondents (5%) possessed a doctoral-level degree in psychology but were not yet licensed. The limited number of licensed psychologists included in the study means that findings cannot be generalized to the larger populations of psychologists or APA members. The online questionnaire was developed specifically for the purposes of this descriptive study, although the format is similar to ethics questionnaires used in past research on the beliefs and behaviors of psychologists (e.g., McMinn, Buchanan, Ellens, & Ryan, 1999; Pope, Tabachnick, & Keith-Spiegel, 1987). It featured 14 questions intended to gather information about participants’ current use of SNWs and other online activities, beliefs about possible regulation of online activities by the APA, and interesting or difficult encounters participants have had with clients as a result of online activities. Nine of the 14 questions were rated on two separate 5-point Likert-type rating scales— one scale based on 155 whether the respondent engages in this practice (1 ⫽ never to 5 ⫽ very often) and one scale based on whether the respondent believes the behavior to be ethical (from 1 ⫽ unquestionably not to 5 ⫽ unquestionably yes). An additional item asked respondents whether they maintained a SNW (yes or no) and then asked respondents to rank the ethics of doing so on the same 5-point Likert-type scale used for other ethics ratings. For those respondents who did maintain a SNW, they were asked if the page was set to “private.” Respondents were also asked whether they thought APA should create ethical standards around the use of Web resources, rated on a Likert-type scale ranging from 1 (definitely no) to 5 (definitely yes). They were also asked whether they had thought about possible ethics and safety ramifications of SNWs, rated on a Likert-type scale ranging from 1 (not at all) to 5 (a great deal). The survey also featured a short demographics section and an open-ended question asking respondents to describe a challenging or interesting interaction with a client regarding online activities. The majority of participants (77%) reported maintaining a page on an SNW. Of those who do have an SNW, most (85%) reported they were using privacy settings to protect their personal information. As expected, there was a significant negative correlation (r ⫽ –.45, p ⬍ .01), indicating that younger respondents were more likely to maintain an SNW than older respondents. Although there were only 15 respondents over the age of 54 in the sample, none of them reported that they maintained an SNW. In contrast, 86% of the 528 respondents under the age of 30 did. Participants ranked nine behaviors (shown in Table 1) according to how often they had engaged in the particular behavior. The behaviors are listed in order from those most frequently engaged in to those least frequently engaged in by survey participants. A repeated measures multivariate analysis of variance (MANOVA) indicated overall differences in the ratings, Wilks’s ⌳(8, 508) ⫽ .26, p ⬍ .05. Adjacent items were then compared using a profile analyses with paired sample t tests to determine which items on the list were rated significantly differently from the items preceding them. Significant differences were observed for all but one of the adjacent means. In particular, participants stated that they would reject or ignore attempted client contact by SNWs (a rating of 3.4) Table 1 Behaviors Ordered by Frequency of Reported Occurrence Comparison with previous item Item M SD t(8) d Rejecting or ignoring a client when they attempt to make contact through a social networking website Posting photos or video of self on a website for private use Posting photos or video clips of friends or family members online Allowing clients to e-mail you Using phony names or photos when engaging in online activities in order to disguise identity Searching for a client on a social networking website Posting photos or video clips of self on a website for professional use Working with clients who learned of you through an Internet search Discussing aspects of online activities with clients 3.4 2.9 2.8 1.8 1.5 1.3 1.2 1.2 1.1 1.8 1.3 1.3 1.1 1.1 0.6 0.6 0.6 0.3 5.4ⴱⴱ 3.3ⴱ 15.8ⴱⴱ 3.8ⴱⴱ 6.3ⴱⴱ 2.6ⴱⴱ 1.6 2.9ⴱ 0.28 0.07 0.88 0.21 0.28 0.18 0.17 Note. Ratings were provided on a Likert-type rating scale based on whether the respondent engaged in this practice, ranging from 1 ⫽ never to 5 ⫽ very often. The t values are reported for paired samples t tests, and d values are reported for effect size using Cohen’s d. ⴱ p ⬍ .01. ⴱⴱ p ⬍ .001. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 156 TAYLOR, MCMINN, BUFFORD, AND CHANG but often posted photos or videos of themselves (a rating of 2.9) and family or friends (a rating of 2.8); all of these behaviors were much more likely than the other behaviors investigated (Cohen’s d ⬎ 0.88). These same nine items—plus an item about a psychologist having an SNW—were also rated on the basis of how ethical they were perceived to be and are reported in Table 2. A repeated measures MANOVA demonstrated overall differences among the ethics ratings, Wilks’s ⌳(9, 656) ⫽ .18, p ⬍ .05. Adjacent ethics ratings were then compared using a profile analyses with paired sample t tests. When asked to rate the amount of thought they had given to the ramifications of using SNWs, most participants (n ⫽ 407) reported that they have thought about this issue either somewhat (a rating of 3) or quite a lot (a rating of 4), with an overall mean rating of 3.6 on the 5-point Likert-type scale. Only 56 people reported that they had not thought about the ramifications of using SNWs at all. A negative correlation was found between age and the degree to which a person reported having thought about the ramifications of using SNWs (r ⫽ –.23, p ⬍ .01). Respondents were also asked whether they would like APA to impose specific rules and guidelines regarding the use of Web sites, including SNWs. There was no clear consensus on this matter, with a mean rating near the midpoint of 3 on the 5-point Likert-type scale (M ⫽ 3.2, SD ⫽ 1.2). A small but significant negative correlation was found with age (r ⫽ –.16, p ⬍ .01). This correlation indicated that the younger a respondent was, the more likely he or she was to favor APA involvement in these issues. A total of 100 individuals also provided qualitative information about challenges they have faced regarding use of SNWs or other online activities. Several different themes came up in numerous responses. Many respondents provided personal stories about discovering that they shared common friends or acquaintances with their clients through SNWs. Most of these respondents stated that they promptly removed their pages entirely or altered the content of their pages after discovering the connections. Many other respondents reported that they maintain SNWs, but that they try to avoid ethical problems by keeping their pages set to the highest privacy settings available. Some of these people stated that they do not use their real names on pages or that they use only a first name. Several respondents drew a distinction between issues that arise when they are working as a professor as opposed to working as a psychotherapist. Of these participants, many expressed the opinion that students were more likely to try to contact them through an SNW than clients were. Most stated that they maintain the same personal policy toward students that they use for clients, which is no contact with students via SNWs. Many respondents made a point of stating that they feel it is very important for the strength of the psychotherapy relationship to discuss attempts by clients to contact their psychotherapist online in the next face-to-face session. Other concerns mentioned included inadvertently coming into contact with clients or relatives of clients on dating Web sites, clients mentioning suicidal or homicidal ideation on blogs or Web sites, and clients who want to be contacted via e-mail because they do not have a telephone. Professional Implications MySpace was launched in August 2003 and Facebook in February 2004. Since the introduction of these sites, millions of people worldwide have joined SNWs by posting their own pages. These sites provide entertainment and communication opportunities, but they also present unique ethical and safety issues for psychologists who must be vigilant about issues of self-disclosure, client confidentiality, and safety. Early Career Psychologists, Graduate Students, and SNWs Of the mostly early career psychologists and doctoral-level psychology students who participated in this study, 77.3% reported that they communicate with friends and family through SNWs. On the basis of this survey, it seems that respondents with SNWs are aware of the clinical and ethical implications, but it also seems Table 2 Ethics of Behaviors Ordered by Degree of Endorsement Comparison with previous item Item M SD t(9) d Posting photos or video of self on a website for private use Posting photos or video clips of friends or family members online Maintaining a page on a social networking website Working with clients who learned of you through an Internet search Rejecting or ignoring a client when they attempt to make contact through a social networking website Posting photos or video clips of self on a website for professional use Using phony names or photos when engaging in online activities in order to disguise identity Allowing clients to e-mail you Discussing aspects of online activities with clients Searching for a client on a social networking website 4.1 4.0 3.9 3.7 3.7 3.6 3.3 3.2 2.1 2.0 0.8 0.9 0.8 1.0 1.2 1.1 1.2 1.1 0.9 1.0 6.3ⴱⴱ 1.6 5.6ⴱⴱ 0.6 1.5 5.5ⴱⴱ 1.7 23.3ⴱⴱ 3.4ⴱ 0.18 0.28 0.27 1.05 0.14 Note. Ratings were provided on a Likert-type rating scale based on whether the respondent believes the practice to be ethical, ranging from 1 ⫽ unquestionably not to 5 ⫽ unquestionably yes. The t values are reported for paired samples t tests, and d values are reported for effect size using Cohen’s d. ⴱ p ⬍ .01. ⴱⴱ p ⬍ .001. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. SOCIAL NETWORKING WEB SITES evident that SNWs amplify the possibilities of unintentional disclosures to and encounters with clients. The relationship of age to SNW use is intriguing for at least three reasons. First, psychologists with the least amount of professional experience will be facing some of the most complex situations regarding the distinction between professional and private information. Normally, early career psychologists could look to more experienced psychologists in situations such as this, but if the more experienced psychologists do not understand the nuances of SNWs, they are not likely to be able to provide helpful consultation on this matter. Students may avoid seeking guidance on these issues because of a perceived lack of knowledge regarding these issues on the part of supervisors. Technology could create a threat to usual patterns of supervision that occur in professional psychology. These early career psychologists were also more likely than their more experienced colleagues to express a desire for APA involvement in these issues. It seems that these early career psychologists want more guidance and supervision on these difficult issues. In addition, there may be ethical issues about the use of SNWs in investigating students for placement decisions because training directors of doctoral programs, practicum sites, and internships can access the information on these sites, just as anyone else can (Lehavot, 2009). In some cases, students or employees may be reluctant to bring up issues related to SNWs or the Internet out of a fear that their supervisors will then decide to search for information about the supervisees online. Because SNWs are most prevalently used by young early career psychologists and graduate students, it would not be difficult to predict that this social phenomenon could be underestimated or overlooked by APA leaders, who tend to be older, more established psychologists, and are thus less likely to use these technologies. McMinn, Hathaway, Woods, and Snow (2009) recently surveyed APA council representatives and division presidents and reported an average age of 58.5 years, which is notable because not a single respondent over the age of 54 in the current study maintained an SNW. It is encouraging that APA Ethics Director Stephen Behnke has recently devoted two APA Monitor on Psychology columns to the complexity of ethics situations that arise because of the Internet (Behnke, 2007, 2008). Third, it seems likely that technological changes may drastically affect the way clients and psychologists associate in the future. Youthful clients may use SNW and other online resources as a point of connection with their psychotherapists. Schwartz (1993) discussed psychotherapist self-disclosure as a means of achieving a better match between client and psychotherapist. He asserted that closeness, match, and relationship are so important to the success of psychotherapy that some sharing on the part of the psychotherapist may be necessary for the client to be able to make an informed choice when selecting a psychotherapist and to continue to feel bonded to that psychotherapist over the course of their work together. It seems that clients and psychotherapists in their 20s and 30s are using SNWs as one possible way to make these connections. Clients may seek the match Schwartz discussed by learning more about potential psychotherapists online. In the present study, respondents reported very little online communication with clients, and they saw this as ethically problematic. Never was the most common response for participants in this study when asked how often they allow clients to e-mail them, search for a client on an SNW, or work with a client who learned of them through an 157 Internet search. But as culture changes and computers and wireless technology become increasingly prominent means of communicating, it seems possible that psychologists will become more accepting of this as a way to communicate and connect with clients and potential clients. If so, this raises interesting professional and ethical challenges as the distinctions between private and public blur (Behnke, 2008). Online communications can also be more casual and spontaneous than other types of interactions, often leading people to disclose information online that they would have otherwise withheld (Gutheil & Simon, 2005). The Demise of Intentionality The greater concern about Internet communications may not be the ubiquity of communication but the diminishing of intentionality. All psychologists make disclosures to clients. For example, it would be inconceivable for a psychologist not to disclose his or her office location or fee structure. Some make more personal disclosures, such as marital status, the number of children they have, their religious affiliation, and so on. These disclosures may help establish rapport by helping the psychologist be perceived as honest, accessible, and genuine (Maroda, 1999), whereas excessive or unintentional disclosures may easily shift the focus of therapy away from the client and damage the psychotherapeutic relationship (Bridges, 2001). Regardless of how much a psychologist discloses, it is important to have personal guidelines around self-disclosure. Myers and Hayes (2006) emphasize the importance that all self-disclosure decisions made by psychotherapists be grounded in an underlying rationale. They stated that making decisions about self-disclosure is unavoidable in therapeutic work, but that psychotherapists must structure personal guidelines around theory and ethics and be able to explain their decisions if called on to do so. Even when a psychologist creates concrete guidelines for himself or herself around the area of self-disclosure, the Internet can potentially counteract even the best of intentions on the part of an ethical psychologist. This is not to say that some intentionality is no longer possible, but full intentionality is a thing of the past. Psychologists can be cautious in their privacy settings on SNWs, and many in the present study were. Alternatively, psychologists may choose not to have an SNW at all. But even with this choice, the widespread availability of search engines makes virtually any psychologist easy to research. Clients with an Internet connection have free access to some public records, and for a small fee many sites make other records available. Intentionality about self-disclosure is an important issue, but full intentionality may be impossible. How can psychologists manage professional work in a time when information can no longer be kept from inquiring clients? This is a professional issue that needs to be discussed in various venues. The Dilemma of Regulation and Need for Training Respondents in the present study expressed uncertainty, or perhaps ambivalence, as to whether the APA should be involved in establishing guidelines or regulations regarding Internet communications with clients. This uncertainty is reasonable considering the situation in which psychologists find themselves. On one hand, psychologists and graduate students in this survey—most of them young and relatively inexperienced in professional psychology— TAYLOR, MCMINN, BUFFORD, AND CHANG This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 158 could benefit from having clear guidelines for how to manage technology advances. On the other hand, technological change is too rapid and ubiquitous to maintain any expectation that the APA Ethics Committee could possibly keep up and publish relevant standards on each new technology that has implications for professional psychology. Other than two iterations of a statement on services by telephone, teleconferencing, and the Internet (APA Ethics Committee, 1997), the committee has tended to avoid efforts to offer advisory or regulatory statements pertaining to technological advances. Rather, it has attempted to coordinate the development of the APA “Ethical Principles of Psychologists and Code of Conduct” (e.g., APA, 2002) in a way that provides guidance for psychologists who will inevitably need to respond to changes in the field, including technological changes. Thus, it seems unlikely that the APA Ethics Committee will set any formal guidelines on the use of SNWs in the near future, and this lack of action is likely the most reasonable response given the accelerating rate of technological change. The APA “Ethical Principles of Psychologists and Code of Conduct” (APA, 2002) states: In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect clients/patients, students, supervisees, research participants, organizational clients, and others from harm. (Principle 2.01e) What are the reasonable steps that psychologists can take in response to the blurring of public and private information resulting from Internet technology? We recommend that graduate programs consider adding some discussion of Internet technologies to their ethics training. Also, continuing education in ethics should address issues created by the growth of Internet communications. Early career psychologists must be asked to consider problems and situations that can arise from their use of the Internet. Many ethics courses and trainings feature the use of vignettes and ask participants to consider what the most ethical course of action would be if they found themselves in a similar situation. These same tactics could be applied to situations involving SNWs and the Internet. The primary guidelines for such training would likely involve maintaining appropriate boundaries with clients, keeping psychotherapy focused on the needs and issues of the clients, and avoiding actions that could cause psychological or emotional harm to clients. Self-Monitoring One of the primary implications of this study, for psychologists and graduate students, is that individual practitioners must establish their own self-monitoring strategies regarding online behavior. Peer consultation, documentation, and thoughtfulness may be the best methods psychologists have to protect themselves. The qualitative data provided by study participants provide some suggestions for prevention of online disclosures. Several participants reported that they announce to students that all attempts to contact them via SNWs will be ignored or rejected. Other study participants recommended that psychologists “Google” themselves to see what comes up through the search. This could be helpful not because one can control the information that circulates on the Internet, but rather so the practitioner would be informed if a client ever brought such information up in psychotherapy. Many respon- dents emphasized the importance of having open discussions in the next session following any online contact with a client. Most stated that they believe being open and honest about such contact can repair any damage to the relationship and can help correct any false interpretations of information obtained online. Also, a number of participants reported that their Web pages are set to the highest allowable levels of security; others stated that they use pseudonyms online for the specific purpose of making it difficult for clients to locate them. Although these suggestions are probably helpful in most cases, other reports served as reminders of the dire possibilities that emerge because of online networking. Some respondents noted that they occasionally found pictures of clients on the Web sites of their friends or family members, and that they had no prior knowledge of these relationships. A few participants even reported that they had been matched to current or former clients through anonymous dating Web sites. It seems clear that psychologists must consider the potential risks and consequences associated with maintaining SNWs. For psychologists who choose to maintain a page on one of these sites, a number of important decisions must be made regarding whether or not the site will be set to private, how they will handle attempts by clients to make contact with them, and what specific content they will post on their page. Considering the “small-world hazards” that rural psychologists often face, and how they manage these hazards, may serve as a helpful point of comparison for psychologists with SNWs (Campbell & Gordon, 1993). Rural psychologists almost inevitably have unplanned encounters with some of their clients because of the size of the communities in which they live and practice. The Internet harbors similar hazards because psychologists have little control over when, where, and how their clients may encounter information about them online. Psychologists must take reasonable actions to avoid foreseeable problems with online information, and they must be prepared to do damage control after clients seek their information through the Internet. Conclusion This article provides an initial look at the professional and ethical implications of SNWs, but much more research and professional discussion are needed. There are a number of limitations to this study, including the preponderance of graduate student respondents as compared with a small number of psychologist respondents, the relative homogeneity of the sample with regard to age and ethnicity, the exclusive use of electronics to distribute the survey, the limited number of questions posed to respondents, and the possible selection bias among those who chose to respond to the survey. More research and professional conversation are needed to explore further the topic of SNWs and related topics. We have focused on the beliefs and behaviors of psychologists regarding SNWs, but it would also be interesting to find out more about the online behavior of psychotherapy clients. It would be helpful to know the types of information clients seek when searching for a psychotherapist online, and which information has the greatest impact on the client’s ability to work effectively with the psychotherapist. It seems reasonable to hypothesize that self-disclosures made through SNWs might affect the therapeutic relationship in SOCIAL NETWORKING WEB SITES ways similar to other forms of self-disclosure, but further research could test this hypothesis. Currently, the percentage of clients who participate in SNWs and the frequency with which they search or try to interact with psychotherapists through this venue are unknown. Future research could examine these questions. In the meantime, we hope this article helps promote conversations among psychologists and those who train psychologists. Technological change is nothing new to psychologists, and more change is certain to come in the future. The challenge facing us now is a familiar one as we attend to the professional and ethical implications of contemporary change. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. References American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060 –1073. American Psychological Association Ethics Committee. (1997, November 5). Services by telephone, teleconferencing, and Internet: A statement by the Ethics Committee of the American Psychological Association. Retrieved from http://www.apa.org/ethics/stmnt01.html Behnke, S. (2007, January). Posting on the Internet: An opportunity for self (and other) reflection. 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Received June 21, 2009 Revision received September 14, 2009 Accepted September 16, 2009 䡲 Instructions to Authors For Instructions to Authors, please consult the February 2010 issue of the volume or visit www.apa.org/ pubs/journals/pro and click on the “Instructions to authors” tab in the Journal Info box.
Professional Psychology: Research and Practice 2014, Vol. 45, No. 1, 11–19 © 2014 American Psychological Association 0735-7028/14/$12.00 DOI: 10.1037/a0033478 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Social Networking and Professional Ethics: Client Searches, Informed Consent, and Disclosure Sara E. Harris Sharon E. Robinson Kurpius Marquette University Arizona State University As mental health professionals are increasingly using technology in their clinical work, it is important that research examines the ethical implications of online behaviors. This study examined the online behaviors of 315 counseling and psychology graduate students. Hierarchical multiple regression was used to examine online client searches, informed consent, and disclosures. Increased disclosure of client information was related to lower scores on ethical decision-making and to program type (counseling, clinical, or school). Ethical decision-making moderated online disclosure for participants in school psychology programs. Of those with supervised clinical experience, a third had used the Internet to find information about a client. Progress in the participants’ academic program, as measured by academic credits, and years of social networking experience were positively related to increased online client searches. The majority who conducted an online search did not obtain client informed consent before conducting the search. Reported therapeutic concern about client welfare and gathering information for intervention were significant predictors of obtaining informed consent. Keywords: social networking, disclosure, informed consent, online client search social networking rose from 61% in 2010 to 65% in 2011, with 43% accessing their account daily (Madden & Zickuhr, 2011). The majority of users are females between the ages of 18 and 29. Although membership for the 18- to 29-year-olds has remained relatively steady, between 83% and 86%, it is increasing for older individuals (Madden & Zickuhr, 2011). For example, online membership rose from 61% in 2010 to 70% in 2011 for 50 to 64-year-olds and from 26% to 33% for those older than 65. That online membership is becoming a cultural norm rather than an exception underscores the importance of research related to this new medium. Mental health professionals are no exception to the trend of social networking use. Studying student members of Divisions 29 (Psychotherapy) and 42 (Psychologists in Independent Practice) of the American Psychological Association (APA), Lehavot, Barnett, and Powers (2010) found that 81% had a social networking site. Focusing on counseling, clinical, and school psychology graduate students, DiLillo and Gale (2011) reported that 71.8% of the 854 students had a social networking site. Another study of 695 mental health students and professionals found that 77% reported maintaining a social networking page (Taylor, McMinn, Bufford, & Chang, 2010). Of the 528 who were under the age of 30, 85% participated in social networking; however, no one over the age of 54 did. A survey of APA Council of Representatives and division presidents conducted by McMinn, Hathaway, Woods, and Snow (2009) also revealed that no one over the age of 54 maintained a social networking site. It is evident that younger mental health professionals are the active members of social networking sites. Additionally, social networking is relatively new and may not be an area in which students and new professionals can turn to their supervisors or university faculty for advice. Social networking sites, such as Facebook, Twitter, Google⫹, Myspace, Classmates.com, Linkedin, and LiveJournal, provide a new medium for people to meet, reconnect, find others with similar interests, network with professionals, share information, and even find love. Social networking is increasingly interwoven into today’s social and business world. When one peruses social networking sites, universities, Fortune 500 companies, advocacy groups, and even churches can be found. Facebook has more than 500 million active users, half of whom access their account daily (Statistics, Facebook.com, 2010). To track the growth of social networking use in the United States, the Pew Research Center has collected yearly data since 2005. The most recent data on more than 2000 individuals over the age of 18 revealed that the percent of adults who participated in SARA E. HARRIS is currently pursuing a PhD in Counseling Psychology at Marquette University and also spends her time as a researcher at the Penfield Children’s Center Behavior Clinic. Her research and professional interests include children’s reactions to traumatic stress, development and validation of pediatric psychological tests, and professional ethics. SHARON E. ROBINSON KURPIUS is a professor and Director of Clinical Training for the Counseling and Counseling Psychology programs at Arizona State University. She holds fellow status in the American Educational Research Association and three divisions of the American Psychological Association (APA)–Counseling Psychology, Consulting Psychology, and Health Psychology. Her research interests include women and health, intimate relationships, ethics and values, academic persistence, and aging. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Sara E. Harris, Marquette University, Department of Counselor Education and Counseling Psychology, College of Education, Schroeder Complex, P. O. Box 1881, Milwaukee WI 53201-1881. E-mail: sara.harris@mu.edu 11 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 12 HARRIS AND ROBINSON KURPIUS Although the APA Ethical Principles (2010) does not specifically address standards for social networking sites, it does assert that the “application of an Ethical Standard may vary depending on the context” (p. 1) and that “The fact that a given conduct is not specifically addressed by an Ethical Standard does not mean that it is necessarily either ethical or unethical” (p. 1). Taylor et al. (2010) found a slight negative correlation between age and favoring APA involvement in providing set standards, with younger participants more likely to favor APA involvement. Any hesitancy, however, related to developing ethical guidelines for social networking may be coming to an end. APA ethics director Stephen Behnke stated “with a very high degree of confidence that when APA does draft the next code, the drafters will be very mindful of many issues being raised by social media” (Martin, 2010, p. 32). The widespread use of social networking is also cited as a catalyst for revision of the American Counseling Association (ACA, 2005) Code of Ethics (Rollins, 2011). The concern of the APA and ACA highlights the need to study professional behaviors related to social networking, particularly behaviors that might be unethical. Social networking creates many complex ethical dilemmas, particularly those related to privacy, confidentiality, and informed consent, which often do not have clear-cut answers. It is critical that psychologists and counselors have an understanding of ethical concepts and subsequent boundaries and transfer this understanding to their professional online behaviors. Privacy refers to the clients’ right to decide how much of their behaviors, thoughts, and feelings they share with others (Koocher & Keith-Spiegel, 2008). APA (2010) Principle E states, psychologists should “respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and selfdetermination.” Mental health professionals respect the client’s choice to disclose information and do not engage in activities that bias their work. For example, learning about a facet of the client’s identity through a social networking site without processing this new information with the client could introduce bias into the therapeutic relationship, compromise the client’s fundamental right to privacy, and place the counselor in a position of knowing something the client has not directly shared. Some have argued that certain instances may warrant examination of a client’s social networking page (DiLillo & Gale, 2011; Martin, 2010). For example, viewing a social networking page of a suicidal client who has missed recent sessions may provide some insight into the client’s whereabouts and state of mind. Information obtained, however, could be inaccurate or be out of context. For example, if a client was being treated for severe alcohol dependence, pictures of him/her “partying” could cause the therapist to be alarmed. The clinician’s interpretation could change drastically if it was revealed that the pictures were taken years ago. Behnke (2008) warned that, “There is a “slippery slope” to seeking and relying on such information that risks turning psychologists into private investigators” (p. 75). Despite ethical guidelines, confidentiality creates some of the most challenging and confusing ethical dilemmas (Koocher & Keith-Spiegel, 2008). Social networking adds a unique layer to the already complex construct; the public or private nature of information posted online is ambiguous. The APA (2010) Ethical Principles state “Psychologists have a primary obligation and take reasonable precautions to protect confidential information ob- tained through or stored in any medium” (p. 7). It could be argued that social networking is a new medium through which mental health professionals can obtain information and that the standards for confidentiality still apply. The importance of clients being informed consumers of therapeutic services is captured in the ethical standards involving informed consent. The APA (2010) emphasizes that informed consent should be readdressed as new circumstances warrant. Somberg, Stone, and Claiborn (1993) examined a variety of contexts in which informed consent should be obtained (e.g., limits of confidentiality, potential risks of therapy) and reasons for not obtaining this consent. Some of the most common reasons included the belief that the issue was not relevant or necessary and that the risk of not obtaining consent was perceived as being low or none. This highlights the role of the clinician’s own personal attribution of importance plays in the informed consent process. The reason for online searches (e.g., verification of information, treatment planning), therefore, may predict whether the clinician obtains informed consent. Despite ethical risks, between 27% and 97.8% of student psychotherapists report seeking client information through the Internet (DiLillo & Gale, 2011; Lehavot et al., 2010). Factors that predict these searches are unclear. A positive correlation between trainee year in program and acceptability of searching for client information using a search engine was noted in one study (DiLillo & Gale, 2011). Explanations of this finding were not provided by the researchers. Could the finding be the result of the passage of time or the result of a third variable such as increased exposure to clients? Another factor that likely contributes to online client searches is years of social networking experience. Individuals who have been members of social networking sites for many years may be more familiar with how to navigate these websites and feel more comfortable conducting a search through this medium. Few studies have examined online disclosures, particularly disclosures related to clients. Frye and Dornish (2010) found that experience with social networking communication tools was related to increased comfort in self-disclosing, regardless of the perceived level of privacy, and speculated that the link between privacy concerns and online disclosure may be attributed to individuals’ perceived level of knowledge surrounding privacy settings and the belief that others would be unlikely to intercept the communication. In contrast, Zur, Williams, Lehavot, and Knapp (2009) argued that young professionals have grown up with the Internet and personal disclosures on this medium have become ingrained as a part of life. They warned that students might need support in examining their disclosures from a clinical perspective. Instruction on ethical standards may vary by program type (school, counseling, clinical) and by individual institution. For example, some programs require a formal ethics class while others have ethics embedded into their coursework and practicum classes. Interest and expertise in ethics, as reflected by major areas of research interest also varies by program, with 18% of counseling psychology programs and 6% of clinical psychology programs citing professional ethics as a focal area (Norcross, Sayette, Mayne, Karg, & Turkson, 1998). Pope and Vetter (1992) studied a random sample of current APA members and found that confidentiality was the most frequently encountered ethical dilemma (18%). This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. SOCIAL NETWORKING AND PROFESSIONAL ETHICS Similarly, Dailor and Jacobs (2011) conducted a survey of practitioner members of the National Association of School Psychologists and found that 33% had witnessed an ethical transgression regarding confidentiality. This suggests that issues surrounding confidentiality may pose additional complications for school psychologists compared with those in counseling or clinical psychology programs. This may be attributed to the complexities of disclosure (e.g., balancing student confidentiality with parental rights) within a school setting. Issues surrounding confidentiality and disclosure are also cited as the most common and challenging ethical concerns among counselors in a school setting (Bodenhorn, 2006). Although these behaviors are observed in person, they may also transfer to the online environment. It is important to note that individuals who share information about their clients (overtly or covertly) online may also be at greater risk of violating other professional boundaries. However, individuals with better ethical decisionmaking may be less likely to engage in unethical behaviors despite program affiliation/training. Although sharing personally identifying information about a client without the client’s consent is a clear violation of APA (2010) Ethical Principles, other disclosures may not be as clear-cut. For example, would it be acceptable to casually express displeasure online by stating that an unnamed client missed an appointment? Issues surrounding disclosures have already caused lawsuits in the field of medicine. A recent court case, Doe v. Green, involved a paramedic who disclosed details on a social networking site that he thought did not overtly identify (e.g., name) the victim of a rape (Clark, 2010). Although Green’s intentions may have been to warn other potential victims, he provided information on his Web site that the survivor thought was identifiable and that resulted in a lawsuit. Such risk exists for all professionals who have an ethical and legal obligation surrounding client confidentiality. It is important to increase awareness of the possible damage that can be caused by a metaphorical slip of the finger. Even with adequate consent, Koocher and Keith-Spiegel (2008) recommended that professional caution be used before sharing any information through a news outlet and identified “inadequate anticipation” of consequences as one of the “risky conditions” that can lead to ethical dilemmas (p. 16). Thus, it is important that potential ethical dilemmas related to social networking sites are addressed in graduate training and current professional behaviors and beliefs surrounding social networking participation are explored. The current study examined the online practices of counseling and psychology graduate students and generated hierarchical regression models for online client searches, best practices in informed consent, and disclosure. Two specific hypotheses were addressed: (1) Lower scores on ethical decision-making, greater experience with social networking, more perceived knowledge of privacy settings, enrollment in a school psychology or school counseling program, and the interaction of ethical decision making and program type will be related to more disclosure of client information on social networking; and (2) Credits, direct client hours, and years of social networking experience will be positively related to online searches of client information. Additionally, one exploratory analysis was con- 13 ducted to examine whether reason for online search would predict obtaining informed consent. Method Participants and Procedures After Institutional Review Board approval was obtained, graduate students in counseling and in psychology programs were recruited by sending emails to liaisons of Council of Counseling and Related Educational Programs (CACREP) programs and to Directors of Clinical Training (DCT) for psychology programs. Interested students were directed to the Survey Gizmo Web site where they gave consent to participate before completing the survey. Approximately 77.5% of those who opened the survey completed it. As incentive for completing the questionnaire, participants were offered the opportunity to win one of four $20 Visa gift cards. GⴱAnalyses indicated that a sample size of at least 85 was needed to achieve statistical significance with an alpha of .05, a power level of .80, and a .15 effect size. The 315 graduate students (264 females; 49 males; 2 not identified) who completed the survey resided in 35 states and had an average age of 28.4 years (SD ⫽ 6.21). Most identified as Caucasian/Euro American (n ⫽ 248; 78.5%), with 20 (6.3%) identifying as Asian/Pacific Islander, 17 (5.4%) as Black/African American, 18 (5.7%) as Hispanic/Latino/a, 2 (.6%) as Native American/ Alaska Native, and 11 (3.4.%) as Other/Multi-Racial. Over half (57.4%) were enrolled in a doctoral program. Programs surveyed included counseling (n ⫽ 95; 30.2%), counseling psychology (n ⫽ 76; 24.1%), clinical psychology masters programs (n ⫽ 11; 3.5%), school counseling (n ⫽ 28; 8.9%), school psychology (n ⫽ 59; 18.7%), and clinical psychology doctoral programs (n ⫽ 46; 14.6%). Only 19 (6%) did not belong to a social networking site. Of the 297 who did, 292 (98.6%) had social networking pages on Facebook, 96 (32.8%) on LinkedIn, 91 (30.6%) on YouTube, 87 (29.3%) on Google⫹, 76 (25.5%) on Twitter, 25 (8.4%) on Myspace, 20 (6.7%) on Yelp, and 32 (10.8%) on other social networking sites. On average, students had 2.43 (SD ⫽ 1.5) social network memberships and had maintained their networking page for 5.8 years (SD ⫽ 2.0). More than two thirds (79.7%) accessed at least one of their accounts daily, although the vast majority (92.9%) had accessed at least one of their accounts by the end of the week. Measures Multiple outcome variables were assessed. These included online client searches, informed consent, online disclosures, ethical decision making, and privacy knowledge. Online client searches. Frequency of online client searches was measured by two items: “I have conducted a Google Search to find out or verify information about my client” and “I have conducted a social networking search to find out or verify information about my client.” Each item was responded to on a 6-point Likert-type scale, with anchors ranging from Never (1) to Very Frequently (6). Responses were summed to form a total score that could range from 2 to 12, with higher scores indicating greater frequency of client online searches. For the study This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 14 HARRIS AND ROBINSON KURPIUS sample, the coefficient alpha was .73 and scale mean was 2.86 (SD ⫽ 1.57). Informed consent. Five items, derived from the APA (2010) and ACA (2005) ethical standards to assess best practices in informed consent and identified by Somberg et al. (1993) as important elements of informed consent (i.e., limits of confidentiality, potential risks of therapy, length of treatment, possible procedures used, and alternatives to therapy), were used to measure Informed Consent. Each item was rated on a scale from 1 (Never) to 6 (Very Frequently). Sample items include the following: “I obtained informed consent from my clients before conducting an online search (e.g., Social networking, Google)” and “I discussed with my client the benefits and drawbacks of conducting an online search about them.” Responses were summed to form a total score, with higher scores indicating more use of informed consent practices. Total scores could range from 5 to 30. For the current sample, the scale mean was 7.25 (SD ⫽ 5.33), and the coefficient alpha was .93. Online disclosures. The extent to which participants disclosed client information online was assessed by eight items rated on a 6-point Likert-type scale (1 ⫽ Never to 6 ⫽ Very Frequently). Sample items include the following: “I have expressed positive thoughts/feelings (e.g., happiness, optimism, hopefulness, etc.) online about a client but did not provide information that I believe could readily identify the client”; “I have posted an update online that indirectly referenced negative thoughts/feelings (e.g., disappointment, frustration, sadness, etc.) I was having about a client”; and “I would warn my online friends about a client who is dangerous.” Total scores, which could range from 8 to 48, were calculated by summing responses across the items. Higher scores reflect more disclosure. For the current sample, the scale mean was 9.81 (SD ⫽ 3.68), and the coefficient alpha was .84. Ethical decision-making. The ethical decision-making subscale of Kendall et al. (2011) Boundaries in Practice measure, which includes 10 scenarios to assess ethical decision-making, was used. A sample scenario was “You have been under a lot of personal stress and the client asks you what is wrong. You find yourself telling the client about your problems.” For each scenario the participant was asked, “How ethical is this decision?” Decisions were rated on a 4-point Likert-type scale, with anchors ranging from Never Ethical (4) to Always Ethical (1). In addition, another item, “You begin therapy with a client and you find that you are attracted to each other” was presented for the sexual attraction scenario. This resulted in an 11-item scale with responses summed across items. Scores could range from 11 to 44. Higher total scores reflect belief that scenarios were not ethical and indicate good-decision making. Kendall et al. (2011) established content and face validity through use of expert panel ratings. They reported a coefficient alpha of .86. For the current study, the coefficient alpha was .75, and the scale mean was 38.87 (SD ⫽ 2.99). Privacy knowledge. Four items assessed perceived knowledge of privacy settings. These items included: “I feel confident about my knowledge of privacy settings on my social networking sites”; “I am aware of what information is viewable by the public (i.e., nonfriends) on my social networking site”; “There may be information on my social networking page that can be viewed by the public that I did not intend to be publicly viewable”; and “I do not know what information the public can view on my social networking site.” Items were responded to on a 6-point Likert-type scale, with anchors ranging from Strongly Disagree (1) to Strongly Agree (6). After reverse coding the last two items, responses were summed to form a total score, which could range from 5 to 24. Higher total scores indicated more reported knowledge of privacy settings. For the current study, the Coefficient alpha was .81, and the scale mean was 17.90 (SD ⫽ 3.78). Results Descriptive Analyses Before analyzing the research hypotheses, descriptive summaries were calculated for online behaviors. Of the 226 participants who endorsed having clinical experience, 75 (33.2%) had used the Internet to find out information about a client, with 44 (19.5%) using social networking Web sites (e.g., Facebook) to obtain information and 66 (29.2%) using a search engines (e.g., Google) to obtain information. Of those who conducted an online search, 16 (21.3%) did so occasionally to very frequently. Of those who conducted a social network search, 11 (25%) did so occasionally to very frequently. It is important to note that participants with clinical experience who conducted these searches on more than a periodic basis reflected less than 1% of the sample. Of the 75 participants who indicated that they had conducted an online client search, 74 provided information regarding their informed consent practices. The majority, 62 (83.8%), reported that they did not discuss how they would handle information that required a breach of confidentiality with the client, 62 (83.8%) reported never obtaining informed consent prior to online client search, and 64 (86.5%) indicated that they did not document the online search in the client’s file. Participants’ responses to the disclosure items were analyzed for the 226 graduate students who had clinical experience. Two participants did not respond to every question. Twenty (8.9%) of the participants endorsed expressing positive thoughts/feelings online about something a client said in session in comparison to 12 (5.3%) who endorsed expressing negative thoughts/feelings online about something a client said in session. Forty-one (18.2%) endorsed posting an update online that indirectly referenced positive thoughts/feelings (e.g., happiness, optimism, hopefulness, etc.) they were having about a client. Hypothesis Testing Missing data exceeded 5% (n ⫽ 14) for the online client search prediction model (H2); thus multiple imputation was used to account for missing data. All variables in the analysis and auxiliary variables that correlated to variables that were missing were included in the imputation model. Missing data were less than 5% for the disclosure (H1) prediction model and for the informed consent exploratory analysis. The missing value analyses did not reveal patterns for missingness; thus, these cases were not included. Because the dependent measures were positively skewed and displayed high levels of kurtosis, the plots of the observed and predicted residuals were examined for each analysis. To reduce heteroscedasticity and non-normality in residual distributions, the dependent variables were transformed using a log transformation. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. SOCIAL NETWORKING AND PROFESSIONAL ETHICS This improved the distribution of the residuals and linearization of the relationships. Because online use differs across age and gender, the first and second hypotheses controlled for these variables by adding them into the first level of the analyses. Program type (e.g., school psychology, counseling psychology) was controlled for in the second hypothesis and the exploratory analysis to rule out possible confounds. Masters students in clinical psychology programs were collapsed into one group with doctoral clinical psychology programs because separating them had no predictive value and provided little information because of low sample size (n ⫽ 11). Results from the analysis for disclosure of client information online (H1) are summarized in Table 1. The demographics level (age, sex, program) was significantly related to online disclosure, F(6, 212) ⫽ 3.12, p ⫽ .006. The individual differences level (ethical decision making, years of social networking experience, and knowledge of privacy settings) accounted for significant additional variance, F(9, 209) ⫽ 4.84, p ⬍ .001. The full model that included the interaction of program and ethical decision-making was explored in the third level to test for a moderator effect, which was significant, F(13, 205) ⫽ 4.53, p ⬍ .001. Disclosure of client information was related to lower scores on ethical decision-making, t ⫽ ⫺2.10, p ⫽ .037. Enrollment in a school psychology program as opposed to a 15 clinical or counseling program was positively related to disclosure of client information, t ⫽ 2.87, p ⫽ .004. However, status in a school psychology program was moderated by ethical decision-making, t ⫽ ⫺2.67, p ⫽ .008. In other words, although participants in school psychology group had highest scores overall on disclosure items, they had lower levels of disclosure when ethical decision-making scores were high in comparison with the clinical and counseling groups. Results from the analysis for online search of client information (H2) are summarized in Table 2. Possible confounding from age, sex, and program type was controlled in the demographics level. The individual differences level (credits, years of social networking experience, and direct client hours) was a significant predictor of online client searches, F(9, 216) ⫽ 2.52, p ⬍ .001. Online client searches were positively related to years of social networking, t ⫽ 2.64, p ⫽ .008 and to credit hours, t ⫽ 3.01, p ⫽ .003. In other words, years of social networking experience and longer presence in a graduate program were related to increased searching for client information. Exploratory Analysis The results from the analysis for obtaining informed consent before an online search are summarized in Table 3. Possible confounding Table 1 Hierarchical Multiple Regression for Disclosure of Client Information Online (n ⫽ 219) Model R2 1. Demographics Age Sex Program1 Program2 Program3 Program4 2. Individual differences Ethicsc Years SNW Privacy knowledge 3. Full model with interactions Age Sex Program1 Program2 Program3 Program4 Ethicsc Years SNW Privacy knowledge Program1 ⫻ Ethicsc Program2 ⫻ Ethicsc Program3 ⫻ Ethicsc Program4 ⫻ Ethicsc .082ⴱⴱ .173ⴱⴱⴱ .223ⴱⴱⴱ ⌬R2 .092ⴱⴱⴱ .049ⴱ B sr2 SEB p ⫺.001 ⫺.004 ⫺.026 ⫺.013 .041 ⫺.048ⴱ .001 .021 .021 .030 .022 .024 .275 .862 .233 .664 .063 .047 ⫺.07 ⫺.01 ⫺.08 ⫺.03 .12 ⫺.14 ⫺.010ⴱⴱⴱ .006 ⬍.001 .002 .004 .002 ⬍.001 .142 .790 ⫺.29 .10 .02 ⫺.001 ⫺.002 .064 .294 .309ⴱⴱ .029 ⫺.006ⴱ .006 ⬍.001 ⫺.006 ⫺.020 ⫺.019ⴱⴱ ⫺.006 .001 .020 .116 .235 .107 .152 .003 .004 .002 .008 .015 .007 .010 .364 .915 .581 .211 .004 .847 .037 .160 .770 .407 .184 .008 .577 .06 .01 .03 .08 .18 .01 ⫺.13 .09 .02 ⫺.05 ⫺.08 ⫺.17 ⫺.03 Note. Dummy coding was used for Sex in which male is coded 1 and female is coded 0. The notation Program1 refers to the dummy code for program type in which counseling psychology is coded “1” and all other groups are coded “0.” The notation Program2 refers to the dummy code for program type in which School Counseling is coded “1” and all other groups are coded “0.” The notation Program3 refers to the dummy code for program type in which School Psychology is coded “1” and all other groups are coded “0.” The notation Program4 refers to the dummy code for program type in which Clinical Psychology is coded “1” and all other groups are coded “0.” The notation Ethicsc refers to ethical decision-making. The notation SNW refers to social networking. Independent measures are centered. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001. HARRIS AND ROBINSON KURPIUS 16 Table 2 Hierarchical Multiple Regression for Online Search of Client Information (n ⫽ 226) This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Model 1. Demographics Age Sex Program1 Program2 Program3 Program4 2. Full model with individual differences Age Sex Program1 Program2 Program3 Program4 Credits Direct client hours Years SNW R2 ⌬R2 .018 .100ⴱⴱⴱ B ⬍.001 .049 ⫺.025 ⫺.016 .025 ⫺.009 p sr2 .002 .033 .034 .048 .035 .038 .948 .135 .467 .742 .472 .806 ⬍.01 .10 ⫺.05 ⫺.02 .05 ⫺.02 .002 .032 .035 .047 .037 .038 ⬍.001 ⬍.001 .005 .490 .078 .062 .628 .679 .424 .003 .276 .008 .05 .12 ⫺.12 ⫺.03 ⫺.03 ⫺.05 .20 ⫺.07 .17 SEB .077ⴱⴱⴱ .001 .057 ⫺.065 ⫺.023 ⫺.015 ⫺.030 ⫺.002ⴱⴱ ⬍.001 .014ⴱⴱ Note. Dummy coding was used for Sex in which male is coded 1 and female is coded 0. The notation Program1 refers to the dummy code for program type in which counseling psychology is coded “1” and all other groups are coded “0.” The notation Program2 refers to the dummy code for program type in which School Counseling is coded “1” and all other groups are coded “0.” The notation Program3 refers to the dummy code for program type in which School Psychology is coded “1” and all other groups are coded “0.” The notation Program4 refers to the dummy code for program type in which Clinical Psychology is coded “1” and all other groups are coded “0.” The notation SNW refers to social networking. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001. from program type was controlled in the demographics level. Because the hypothesis was nondirectional, the alpha was set at .025. The individual differences level (reason for search) approached significance for online client searches F(8, 65) ⫽ 2.30, p ⫽ .031. Curiosity was the most common reason for conducting an online search about a client and was used as the reference group. Endorsements of therapeutic concern about client welfare, t ⫽ 2.04, p ⫽ .045, and gathering information for intervention, t ⫽ 3.46, p ⫽ .001, were Table 3 Hierarchical Multiple Regression for Informed Consent (n ⫽ 74) Model 1. Demographics Program1 Program2 Program3 Program4 2. Full model with individual differences Program1 Program2 Program3 Program4 Reason1 Therapeutic concern Reason2 Information for intervention Reason3 Verify what client told me Reason4 Other R2 ⌬R2 .047 .220ⴱ .174ⴱⴱ SEB p sr2 ⫺.115 ⫺.081 ⫺.025 ⫺.062 .068 .114 .067 .075 .094 .479 .706 .407 ⫺.20 ⫺.08 .04 ⫺.10 ⫺.112 ⫺.087 ⫺.044 ⫺.027 .065 .107 .063 .071 .089 .420 .488 .707 ⫺.19 ⫺.09 ⫺.08 ⫺.04 .141ⴱ .069 .045 .22 .248ⴱⴱ .072 .001 .38 .111 .014 .058 .093 .061 .883 .21 .02 B Note. The notation Program1 refers to the dummy code for program type in which counseling psychology is coded “1” and all other groups are coded “0.” The notation Program2 refers to the dummy code for program type in which School Counseling is coded “1” and all other groups are coded “0.” The notation Program3 refers to the dummy code for program type in which School Psychology is coded “1” and all other groups are coded “0.” The notation Program4 refers to the dummy code for program type in which Clinical Psychology is coded “1” and all other groups are coded “0.” The notation ReasonX refers to the dummy code for reason for search (e.g., therapeutic concern for client welfare) is coded “1” and all other groups are coded “0.” ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. SOCIAL NETWORKING AND PROFESSIONAL ETHICS related to obtaining informed consent. Verifying what the client said and reasons endorsed as “other” were not significant predictors of obtaining informed consent. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Discussion The Internet has made information increasingly easier to obtain. In response to an inquiry, search engines such as Google can generate thousands of results within seconds. This ease may well account for the fact that a third of the study sample who had clinical experience sought client information online. This finding is consistent with Lehavot et al.’s (2010) findings that approximately a fourth of student psychotherapists seek out client information online. The current study explored possible correlates to online searches of client information, including number of credit hours, direct client hours, number of clients seen, and years of social networking experience. Credits and years of social networking were significantly related to online client searches. DiLillo and Gale (2011) reported a positive partial correlation between year in program and endorsement of obtaining information using a search engine and social networking website. The current study had a similar finding. Credit hours, a measure of progress in ones’ program, was positively related to online client searches. A possible reason for this finding could be that the more advanced individuals are in their graduate program the greater likelihood that they will have engaged in online client searches. Interestingly, although credit hours was correlated to online searches, direct client hours was not. This suggests that clinical experience does not appear to have a significant relationship to online searches of client information. However, the sample consisted of graduate students and the range of variability in direct client hours was likely limited compared to those in clinical practice. Of those students with supervised clinical experience, most had completed or were currently enrolled in only one clinical experience (e.g., practicum), which limits the timeframe to only one or two semesters. Years of social networking experience was also positively related to online client searches. Perhaps familiarity or a comfort with technological mediums is related to a greater likelihood of utilizing these mediums in clinical practice. Although online client searches are not inherently unethical, it is important that counseling and psychology graduate students evaluate how any search for client information affects their client’s right to privacy and ensure client informed consent. Of the participants who conducted an online client search, more than 80% indicated that they never obtained client consent, did not document the search in the client’s file, did not consider the possibility of having to breach confidentiality, and never discussed the benefits and drawbacks of the search with their client. Both the APA (2010) and the ACA (2005) conceptualize informed consent as a fluid rather than static element that should be readdressed as new circumstances warrant. The finding related to obtaining informed consent and documenting this consent is alarming in that it suggests potential ethical violations are occurring. When reasons for online searches of clients were examined, curiosity was the most endorsed reason. Conducting an online client search to satisfy personal curiosity could be considered unethical because it violates clients’ fundamental right to privacy. Not surprisingly, conducting an online search of client information 17 for an intervention or out of therapeutic concern was positively related to obtaining informed consent, further underscoring the importance of examining purpose of mental health professionals’ online searches. The second most reported reason was to verify what the client said in session. This could indicate a lack of trust in the client’s truthfulness or ability to convey information accurately. Additionally, if informed consent was not obtained before the search and a discrepancy was found in client’s in-session reports and information obtained online, potential damage to the therapeutic alliance could result. Some have argued that information online is public; therefore, clients cannot expect their online behaviors to be private. Whether or not the client has an expectation of privacy, the intentionality of the clinician needs to be considered. Although it would be considered reasonable to discuss a chance in-person encounter in therapy where the client was observed doing behaviors related to their treatment (e.g., see client who is being treated for substance abuse at a bar drinking), it would generally be considered unethical to observe clients without their knowledge and consent. This also holds true for the online environment. Even though mental health professionals may unintentionally encounter information about their clients online (e.g., client is featured in a prominently displayed online news article), purposefully searching out information without client consent could be considered a violation of a client’s rights. There were significant differences among participants who completed their clinical experience in a school psychology program and those in clinical or counseling programs, with those in school psychology programs endorsing higher levels of disclosure of client information. This difference may be related to differences in norms for clinical sites. For example, school psychologists may be part of a school’s multidisciplinary team (i.e., member of a group for child’s individualized education plan) and be responsible for conveying test results to parents and appropriate school personnel. Level of interaction and interconnectedness among personnel in a school setting versus a community clinic or hospital may influence perceptions of acceptability of disclosure. Furthermore, school psychologists are working with minors on behalf of the school; therefore, they are expected to share information with relevant school personnel as well as with parents. It is possible that this results in having more lax boundaries with respect to sharing client information, both in person and online. The moderating role of ethical decision-making in school psychology programs suggests that additional training in ethics might improve inappropriate disclosure levels. As predicted, lower scores on the ethical decision-making scale correlated with higher levels of disclosure. Although some of the questions in the ethical boundaries scale were blatantly unethical (e.g., planning a relationship with a current client), others involved scenarios that were not as clear-cut (e.g., coming back after your shift is over to check on a client who recently shared distressing information in session). Individuals who rated the ethically questionable in-person scenarios as unethical were also more likely to rate online disclosures of client information under a variety of circumstances as unethical. This suggests that participants who drew a firm line (i.e., endorsed never ethical) for the hypothetical in-person scenarios may be more likely to transfer this stringent practice to their online behaviors. These are self-reported behav- 18 HARRIS AND ROBINSON KURPIUS iors and beliefs, however, and may not be accurate reflections of participants’ actual online behaviors. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Limitations of the Present Study Several limitations need to be noted, including the following: method of survey administration; scale construction; observed effect sizes; and use of a graduate student sample. Although it has become increasingly common to administer surveys online, there is inherent bias in doing so. To complete the survey, the participant had to have a basic familiarity with navigating the Internet, which may have introduced bias given that this study was about social networking use on the Internet. Additionally, the use of survey methods and self-report data can be subject to under reporting as a result of social desirability. It is also important to note that with the exception of the boundaries in practice scale, the senior researcher created measures for online behavior. Although the coefficient alphas indicated adequate internal consistencies for the measures, the construct validity could be strengthened by use of expert raters and having an external sample of practitioners rather than only students. Observed effect sizes were also a limitation. The models accounted for 10% of the variance (for online search of client information) to 22% of the variance (for online disclosure of client information) suggesting that other important variables are still unaccounted for and should be explored in future research. Finally, because the sample consisted of graduate students, results cannot be generalized to professionals in clinical practice. Conclusions In light of the findings of this study, it is clear that mental health graduate students are engaging in activities that are ethically questionable (e.g., conducting an online search without informed consent). Of the 315 participants, more than half reported that they did not believe that their graduate program adequately addressed professional social networking guidelines, and slightly less than half did not believe their professional organization adequately addressed professional social networking guidelines. It is clear that many graduate students are looking for guidance on how to navigate ethical dilemmas created by social networking. Surprisingly, of those who indicated searching for clients online or disclosing client information, a quarter reported that they never discussed social networking use that related to their clinical work with their clinical supervisor. To minimize or avoid ethical and legal infractions regarding online behaviors, mental health graduate students should seek professional consultation from clinical supervisors, keep careful documentation, and thoughtfully consider alternatives. Results of this study indicate that mental health graduate students’ use of social networking in their clinical work warrants further attention from professional organizations and training programs. Discussing technology use in clinical practice and encouraging critical thinking regarding ethically questionable behaviors may reduce potential harm to clients and maintain the publics’ trust in the confidential and nonmaleficent nature of the mental health professional-client relationship. Ethical training could be potentially augmented by including scenarios that encourage the application of the ethical code in cases that are less clearly defined legally or by respective ethical standards (e.g., APA, 2010) as “right” or “wrong.” Even though participants may not believe that the information they share online could reveal client identity, it is difficult to distinguish what degree of disclosure would cross the boundary as identifiable. As previously noted, malpractice suits have been brought against members of the medical field for releasing information that the patient felt could identify them. Furthermore, it is becoming increasingly common for clients to conduct an online search of their mental health professional. Lehavot et al. (2010) found that the majority (70%) of mental health trainees seeing clients were informed by a client that he or she had obtained information about the trainee through the Internet. Imagine the potential damage a therapeutic alliance could suffer if a client found information posted online by their clinician that they believed referenced him/her. Any level of disclosure, even disclosure that the professional does not think is identifiable, runs the risk of violating ethical boundaries. Graduate students need to examine what purpose an online disclosure is serving and whether there is a potential to cause harm to the client. Professional organizations and graduate programs need to address the question of what, if any, client information is acceptable to disclose online. The responsibility for information that is indirectly obtained through social networking is ambiguous, which underscores the importance of openly discussing with the client the intended therapeutic use of social networking. If viewing a client’s social networking page is deemed appropriate by both clinician and client, it is important that mental health professionals are familiar with the state laws regarding when to breach confidentiality. Additionally, the rationale for the search, the potential benefits and anticipated consequences, and discussions with the client need to be documented carefully in the client’s file before conducting any online search. Following these suggested recommendations and generating open discussion among members of the mental health field can help reduce or avoid serious ethical infractions. References American Psychological Association. (2010). American Psychological Association ethical principles of psychologists and code of conduct. Retrieved October 16, 2011, from http://www.apa.org/ethics/code/index .aspx Behnke, S. (2008). Ethics in the age of the internet. Monitor on Psychology, 39, 74 –75. Retrieved from http://www.apa.org/monitor/index.aspx Bodenhorn, N. (2006). 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Training and Education in Professional Psychology 2014, Vol. 8, No. 2, 105–111 © 2014 American Psychological Association 1931-3918/14/$12.00 DOI: 10.1037/tep0000035 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Who’s Googled Whom? Trainees’ Internet and Online Social Networking Experiences, Behaviors, and Attitudes With Clients and Supervisors Penelope A. Asay Ashwini Lal Illinois School of Professional Psychology California State Polytechnic University The ubiquity of the Internet and online social networking creates rapidly developing opportunities and challenges for psychologists and trainees in the domains of relationships, privacy, and connection. As trainees increasingly are natives of an Internet culture, questions arise about the ways in which developing psychologists may view Internet issues and the guidance they receive from professional psychologists for whom the Internet is a significant cultural shift. A national survey of graduate students (n ⫽ 407) assessed student Internet behaviors (e.g., “Googling” clients, online social networking), training about online issues, attitudes toward online social networking and client or supervisor contact via these networks, and fears and comfort about making decisions regarding these networks. The survey also assessed what students reported they would do and what they would think if clients and supervisors contacted them via social networks. Results indicate that most trainees have changed and monitored their online presence since beginning graduate school. A quarter of respondents had “Googled” clients, and almost half had “Googled” supervisors. A small number indicated that both clients and supervisors had reported “Googling” the trainee. Students expressed concerns about making ethical decisions about online social networks. Half reported discussing Internet issues in their graduate training programs, whereas a quarter indicated they had discussed Internet issues at their training sites. Implications for training are discussed, with recommendations of program disclosure of Internet policies to students, discussion of Internet issues before trainee clinical work, role plays of ethical issues, and supervisor-initiated discussions of Internet issues. Keywords: ethics, Internet, privacy, supervision, training and Widseth (2012) wrote about the “erosion of aloneness.” Private moments are captured, posted, and sometimes only enjoyed— or experienced—after public recognition and feedback. For the new generation, they wrote, “everything is instantaneous; everything is public and immediate” (Webb & Widseth, 2012, p. 165). Relationally, the Internet and online social networking sites like Facebook are changing how people interact and how people experience self and the world. Work has investigated the implications of technology and online social networking for conceptions of personal privacy, in-person and online relationships (Turkle, 2010), and even changing experiences with death (Kasket, 2012). Recent work suggests that online relationships and interactions have very real impacts on mood and mental health. These impacts can be positive, facilitating interaction and feelings of connectedness and comfort (Alloway & Alloway, 2012; Baker & Oswald, 2012), and negative, especially in increasing instances of cyberbullying (Sengupta & Chaudhuri, 2011; Siegel, 2012). Though some studies have shown an increase in depressive symptoms, for example, with greater use of the Internet (Kraut et al., 2002; Selfhout, Branje, Delsing, Ter Bogt, & Meeus, 2009), others have shown there to be benefits of general Internet use and online social networking (Morgan & Cotton, 2003). The social shifts occurring as a result of the rise of the Internet have naturally attracted much popular and scholarly attention. The implications for personal and professional lives, for what it means to be social, relational beings and how and what people both know and know about each other are substantial. A New York Times article (Rosen, 2010) proclaimed that the Internet means “the end of forgetting.” Traumas, triumphs, missteps, and mundane moments no longer exist merely in personal pasts; rather, they may exist for all to see, for all time. In a world in which people can now be—and are expected to be— constantly connected, it may be increasingly difficult to carve out what is uniquely personal. Webb This article was published Online First March 17, 2014. PENELOPE A. ASAY earned her PhD in counseling psychology from the University of Maryland. She is associate professor at the Illinois School of Professional Psychology, Argosy University, Chicago. Her research interests include clinical training and existential issues in the Internet Age. ASHWINI LAL earned his PsyD from the Illinois School of Professional Psychology. He completed his APA accredited pre-doctoral internship at Northport Veterans Affairs Medical Center, Northport, New York and his post-doctoral residency at California State Polytechnic University, Pomona, California. His interests include mood and anxiety disorders, loss, transitions, and health-behavior related changes. He is currently a contributing author to the website Psychology In Everyday Life. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Penelope A. Asay, Associate Professor, Illinois School of Professional Psychology, Argosy University, Chicago, 225 N. Michigan Avenue, Chicago, IL 60601. E-mail: pasay@argosy.edu Use of Internet Information The individual responsibility of what and how people share on the Internet presents a novel realm of choice. Deciding what to post on a blog or social networking site may be momentary 105 ASAY AND LAL This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 106 decisions with long-term consequences. Employers conduct Internet searches of potential and current employees. Patients seek out information before meeting physicians and psychotherapists. Indeed, Gibbs, Ellison, and Lai (2011) regarded “Googling” (e.g., conducting online searches) those encountered in online dating activities as one example of an “uncertainty reduction strategy” (p. 72). A survey by the Society for Human Resource Management in 2011 reported that 26% of organizations were using search engines and 18% of organizations were using social networking sites to screen job candidates (Society for Human Resource Management, 2011). Results also may have suggested a trend involving a change from “Googling” potential employees to searching online social networking sites. An article in the New England Journal of Medicine (Gorrindo & Groves, 2008) emphasized various issues surrounding the use of the Internet and the ease with which physician information can be obtained. These authors discussed and explored the problems associated with the information the Internet has made available to patients and described methods by which a physician can protect him or herself. The various methods of self-protection included increasing privacy settings on social networking sites, removing slanderous information, talking with patients about how they use the Internet, and creating a professional Web page that allows for specific content to be posted. At the same time, opportunities for utilizing the Internet for professional practice have blossomed. The APA Practice Directorate (2009) advised, “Since you don’t know by which online channel someone will find your practice, connecting all the places where you appear on the Web is important” (p. 8). Psychologist Keely Kolmes developed a Private Practice Social Media Policy that she shares on her Web site (Kolmes, 2013). The policy addresses specifically the issues of “Friending,” “Use of Search Engines,” “Following” (Twitter, blogs), and the almost quaint by comparison “E-mail.” It has rapidly become common practice for clients/patients to conduct Internet searches for health information (Fox, 2011; Lehavot, 2009; Zur, Williams, Lehavot, Knapp, 2009). In light of the new “consumer” mentality, Gottleib (2012) suggested that Internet presence is essential for professional practice and psychotherapists should consider how to utilize Web sites, blogs, and social networking to “brand” themselves. Privacy Kaslow, Patterson, and Gottlieb (2011) asserted that although people know nothing on the Internet is private, “many people willingly post personal information based on a mistaken assumption of privacy” (p. 3). Yet, the very concept of privacy is shifting, authors argued, for new generations. This “new privacy” is “about controlling how many people know-not if anyone knows” (Melber, 2008, p. 22). As the concept of privacy in psychotherapy is integral to its practice and addressed in the Ethical Principles of Psychologists and Code of Conduct (American Psychological Association, 2002), refining or redefining “privacy” is no small feat. Realistically, individuals can only control so much of what is kept private. Once on the Internet, it is usually impossible to remove information, true or false. Being a deeply relational endeavor involving (almost exclusively one-way) personal information disclosure, psychotherapy is particularly impacted by these rapid changes in knowledge acquisition. Psychotherapy literature emphasizes the establishment of trust and the importance and meaningfulness of timing and intention in disclosure. Yet, with information available to both client and psychotherapist outside of psychotherapy, such dimensions are less controllable. Curious clients (and psychotherapists) can find information about political contributions, home purchases, and whereabouts (Gabbard, Kassaw, & Perez-Garcia, 2011). Taylor, McMinn, Bufford, and Chang (2010) referred to this as the “demise of intentionality,” and suggested, “full intentionality is a thing of the past” (p. 157). Psychotherapists (and clients) can also unintentionally find information online or inadvertently have online interaction (e.g., Facebook suggestions for “People You May Know”). The relational and ethical implications for seeking out online information, inadvertently finding information, and requesting contact via social networking are quite different. Considerations of intention, impact, and self-disclosure are crucial factors in deciding what a psychotherapist does with this information. Ethics Much of the literature has explored concerns about ethical issues, training, and clinical implications of “e-professionalism” (Barnett & Russo, 2009; DiLillo & Gale, 2011; Kaslow et al., 2011; Lehavot, 2009; Lehavot, Barnett, & Powers, 2010; Merdian, 2012). A few empirical studies have investigated both graduate students’ and psychologists’ online experience and attitudes (DiLillo & Gale, 2011; Lehavot et al., 2010; Tunick, Mednick & Conroy, 2011). In general, results indicated that psychologists and trainees are experiencing these online interactions with some regularity. In a sample of child psychologists and trainees, 32% reported reading blogs and social networking sites of their clients for a variety of reasons, including curiosity and concern (Tunick, Mednick & Conroy, 2011). “Googling” clients is not uncommon, with 32% of that sample reporting doing so, 27% of a sample of graduate students (Lehavot et al., 2010), and almost the entirety of a sample of psychology doctoral students (97.8%), despite the majority of these believing it was unacceptable to do so (DiLillo & Gale, 2011). Yet, in a sample of graduate students and psychologists, participants reported almost never discussing aspects of online behavior with clients (Taylor et al., 2010). These issues clearly exist in psychotherapy and raise concerns and questions that evolve more rapidly than the answers. Training and Supervision Students are being trained in the midst of these rapidly evolving technologies and emerging issues. A real gap in the literature appears to be attention to the critical realm of supervision. The supervisory relationship is integral not only to providing effective service to clients, but also to developing the trainee’s competence and professionalism. The ways in which supervisors model behavior in the realm of e-professionalism and their ability to discuss these issues with trainees are important. Information seeking on the part of supervisors may be a part of hiring, of monitoring professional development, or of simple curiosity. Supervisors, of course, are just as susceptible to being “Googled” by their supervisees and of having the “small world” problems that supervisees may have with their clients. Similar implications arise in terms of what is known by whom, how, and This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. WHO’S “GOOGLED” WHOM? how (or whether) that knowledge is shared in the supervisory relationship. Just as between trainee and client, cohort differences may be important between supervisee and supervisor. Supervisors may be less knowledgeable than trainees about constantly changing Internet issues, making professional guidance in this realm difficult (Kolmes, 2012). Prensky (2001) identified “digital immigrants,” those who have seen the development of the Internet in their lifetimes, and “digital natives,” the cohort of people who have grown up with the Internet. In a survey of practicing psychologists and graduate students, not one participant over the age of 54 reported having social networking site profile (Taylor et al., 2010). Other work appears to refute this finding (Hogeboom, McDermott, Perrin, Osman, Bell-Ellison, 2010; Wayne, 2010). At the same time, supervisors may have more expertise and sophisticated ways of thinking about implications of Internet issues in therapy. Still, with technology emerging rapidly, it is likely that “digital natives” have a new cultural experience. Internet Issues as Cultural Competence As literature has discussed the new Internet culture (Schirmacher, 2007), with its “inhabitants” described as “digital natives” (Prensky, 2001), “Gen-i”(for “Generation i”) (Yip, 2010) who are “bilingual” in verbal and digital communication (Lehavot, Barnett, & Powers, 2010), it may be helpful to frame dealing with issues of the Internet as a new realm of cultural competence. As with trainees who are more multiculturally competent than their supervisors, trainees who are more Internet savvy may feel at a loss. Trainees may be actively or passively discouraged from addressing Internet issues in supervision, or they may find supervisor responses unhelpful or minimizing (Ancis & Ladany, 2001; Burkard et al., 2006). Authors have suggested this “generation gap” should not preclude rich discussions and encourage supervisors to educate themselves via the literature and their trainees (Myers, Endres, Ruddy, & Zalikovsky, 2012). Graduate programs have also been encouraged to create and communicate clear Internet boundaries and policies (Kaslow et al., 2011; Kolmes, 2012; Myers et al., 2012). Thus, the current study was designed to investigate graduate student trainees’ experiences with, comfort with, and concerns about Internet issues in their training. The study assessed not only trainees’ own behaviors, but also their knowledge of behaviors and feelings about the behaviors of their clients and their supervisors. Because there is no current literature addressing the prevalence of these behaviors in supervision, the authors thought this dimension crucial to add to the discussion. The study also assessed what trainees reported they would do, think, and feel in reaction to social networking contact by both clients and supervisors. Method Participants A total of 407 participants completed the survey. The respondents were 80.6% white, 5.7% African American/black, 3.8% Asian, 4.6% Hispanic, and 5.2% other. Participants identified themselves as 84.4% female, 15.3% male, and 0.3% other. Most participants were attending a clinical psychology program 107 (86.6%), 12% were attending a counseling psychology program, and 1.4% indicated other. Of the participants, 6.5% were enrolled in an M.A. program, 27.8% were enrolled in a Ph.D. program, and 67.6% were enrolled in a Psy.D. program. Participants identified as humanistic/existential (14%), psychodynamic/analytic (30.8%), client-centered (23.8%), cognitive-behavioral (50.1%), feminist/ multicultural (8.7%), and other (15.7%). Participants’ training sites included counseling center (39%), hospital (43%), community health center (59.9%), middle/high school (18%), VA hospital (6.7%), and other (36.9%). Procedure After obtaining IRB approval, data were collected in two waves: in the first wave, the primary investigator sent an e-mail invitation to contacts in Clinical Psychology PsyD programs at several campuses of a national university. In the second wave, the primary investigator sent an e-mail invitation to contacts listed on the APA Web site for all APA-accredited doctoral programs in counseling, clinical, and combined psychology. In both waves, contacts were asked to distribute the invitation to students in their doctoral program. Participants clicked on a link that took them to an informed consent page. Upon clicking “Next,” they went to the survey. Measure The researchers created a survey instrument for the purposes of exploring online social networking habits, experiences, and concerns. The survey consisted of yes/no and Likert-scale questions in addition to having blank space for any additional comments from participants. The survey included questions about habits and attitudes, ethical concerns, and level of comfort. The survey included questions regarding thoughts about and experiences with clients and with supervisors. A scale that was created to assess trainees’ professional self-disclosure attitudes and behaviors did not have adequate internal consistency, and was thus dropped from analysis. Results Personal and Training Behavior Prevalence Of the 407 participants, 93% (378) indicated they have a social networking account. Most thought social networking accounts were a good way to stay in touch with friends (88.4%), and only 6.9% reported they were a waste of time (these two responses were not mutually exclusive). Since starting graduate school, 74% indicated they had changed the content of their social networking accounts: 89.7% changed privacy settings, 61.1% modified pictures, and 56.8% changed personal information. Since starting graduate school, 74% of participants reported “Googling” themselves. Two thirds (64.4%) indicated they had discussed Internet issues in their graduate programs. Most often, these discussions were in ethics classes (51.5%), followed by professional orientation classes (44.6%), special discussions (24.8%), and other (25.6%). In contrast, only a fourth of students (25.6%) indicated they had discussed these issues at training sites. ASAY AND LAL 108 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Table 1 Professional Behavior Prevalence Statements Yes (%) I have had other professional colleagues contact me via my social networking account I have discussed social networking accounts with my clients I have had my supervisors contact me via my social networking account I have had clients contact me via my social networking account I have searched the Internet for other professional colleagues I have searched the Internet for my supervisor I have searched the Internet for my clients Other professional colleagues have told me they searched the Internet for me My clients have told me they searched the Internet for me My supervisor has told me he/she searched the Internet for me 56.2 25.9 8.5 6.5 63.7 44.5 25.6 24.1 11.4 2.7 Professional Behavior Prevalence Responses suggest that, overall, most trainees are neither seeking out information or contact nor are they aware of being the subject of searches or online contact (see Table 1). Still, more than a fourth (25.6%) indicated they had “Googled” clients, almost half (44.6%) indicated they had “Googled” supervisors, and almost two thirds (63.7%) had “Googled” other professional colleagues. Some reported that clients had disclosed to them that they had “Googled” the trainee (11.4%), whereas almost none indicated their supervisors had (2.7%). As for social networking sites, 6.5% indicated clients had contacted them via these sites, 8.5% indicated supervisors had contacted them, and 56.2% indicated other colleagues contacted them. In psychotherapy, the majority (74.1%) of participants indicated they had not discussed social networking at all with clients. Of those who had, the client brought up the issue the majority of the time (61.6%). Concerns and Comfort In terms of ethical concerns, 72.5% of respondents indicated they were either “concerned” or “very concerned” about the ethical implications of contacting their clients on social networking sites. Forty-three percent indicated concern about the ethical implications of contacting their supervisors while engaged in a supervisory relationship; however, once the relationship had concluded, only 21% indicated concern. In terms of comfort, 90.8% of respondents reported they would be “uncomfortable” or “very uncomfortable” if their clients contacted them via social networking while they were engaged in psychotherapy. Similarly, 87.1% reported discomfort with contact after the psychotherapy had concluded. If a supervisor contacted them while in an ongoing supervisory relationship, 58.1% indicated they would be “uncomfortable” or “very uncomfortable.” Once the relationship had concluded, only 30.5% anticipated discomfort with a supervisor’s contact. More than half (54.5%) indicated they would be concerned about making an ethical decision about contact via their social networking account, and fewer than half (40.3%) indicated they would feel comfortable making an ethical decision about such contact. Tables 2 and 3 indicate what students would do and think if clients and supervisors contacted them. It seems notable that whereas almost all (96.3%) report they would discuss social network account contact with clients, fewer (72.1%) would bring up the issue with their supervisors. Interestingly, a minority indicated they viewed such contact as an invasion of privacy (24.1% for client contact; 17.4% for supervisor contact). Discussion The current study suggests that most trainees seem aware and concerned about their own personal and professional Internet presence. They reported monitoring their Internet presence since beginning graduate training and modifying their social networking site(s). These behaviors suggest that graduate students are aware that their Internet presence is relevant to their training and professional development, as the literature recommended (Barnett & Russo, 2009), and as previous findings have suggested (Taylor et al., 2010). Respondents also reported attention to these issues in about two thirds of their graduate programs, but only a quarter of their training sites. They are concerned about their ability to make an ethical decision involving social networking contact, and fewer than half were comfortable about making such a decision. Such concerns seem to be increasingly likely to be realized: 11.4% reported they have had clients tell them they had “Googled” the trainee, slightly higher than findings in previous studies (7%; Lehavot et al., 2010). Perhaps these results suggest students are aware of some lack of guidance and training in this area and reflect an appropriate response to a developing professional issue. Notably, trainees distinguish that during or after psychotherapy, online social networking contact from clients is uncomfortable, whereas they are more comfortable with supervisor contact, especially after the conclusion of the relationship. The current study supports previous findings about “Googling” clients: a fourth of the current sample reported having done so. This is a similar number to findings by Lehavot et al. (2010), who Table 2 Hypothetical Responses to Client Contact via Online Social Networking Site I would . . . Percent % Discuss it with my client Tell my supervisor Tell other professional colleagues Consider it an invasion of my privacy Consider it a sign of some client psychopathology Consider it a sign of the strength of the relationship Not think too much of it at all 96.3 94.5 30.2 24.1 6.6 5.8 2.1 WHO’S “GOOGLED” WHOM? This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Table 3 Hypothetical Responses to Supervisor Contact via Social Networking Site I would . . . Percent % Discuss it with my supervisor Not think too much of it at all Tell other professional colleagues Tell my training departmentt/member of my school Consider it an invasion of my privacy Consider it a sign of the strength of the relationship Consider it a sign of some supervisor psychopathology 72.1 22.9 21.9 20.3 17.4 12.1 2.9 reported 27% of graduate students had “Googled” clients. Interestingly, a recent study by DiLillo and Gale (2011) reported that almost their entire sample of graduate students (97.8%) reported searching for at least one client’s information in the past year. At the same time, their sample reported clients were aware of overwhelming majority of these searches (Internet: 82.1%; social networking site: 82.5%), although it is unclear whether this was a priori or after the fact. The current study (and previous studies) did not ascertain the client’s knowledge about these searches, and this discrepancy does raise interesting questions. Possibly, such searches are rapidly becoming a more common occurrence within the psychotherapy hour, or at the request of the client, especially with minors (Tunick, Mednick, & Conroy, 2011). In any case, more detail about how such searches are conducted is warranted, especially when they are at the express request or in collaboration with the client. Internet searches can be used and used well therapeutically. Clinton, Silverman, and Brendel (2010) addressed this very notion. They proposed a model of “patient-targeted Googling” that considered the “intention of searching, the anticipated effect of gaining information online, and its potential value and risk for treatment” (p. 105). Their model addressed 6 questions: reason for conducting the search, search benefit or harm to the treatment, addressing whether informed consent should be obtained, determining whether to share the results with the patient, deciding whether to document the findings in the patient’s record, and continually monitoring one’s own motivations for and the risks versus benefits of searching. Discussion of the impact of such a practice on the therapeutic relationship in psychotherapy practice warrants continued attention. The current study appears to be the first to ask trainees what they would do and think in response to hypothetical client and supervisor contact via social networking sites. Interestingly, most would not see such contacts as an invasion of privacy by client or supervisor, although they would still feel uncomfortable about such contacts. Despite deep concerns being raised about privacy (Kaslow et al., 2011; Lehavot, 2009a; Lehavot, 2009b; Lehavot et al., 2010;), perhaps, as Melber (2008) suggested, people’s notion of privacy is evolving with the Internet. Indeed, as trainees and clients are increasingly “digital natives,” such notions may change even more. Respondents in the current study may consider social network sites as a risk worth managing and contact via these sites from clients and supervisors as inevitable (or at least unsurprising). Interesting questions arise about the applicability of the Ethics Code principles on privacy when the very notion of what is private for supervisors, trainees, and clients may be very different. In the current study, one respondent commented, 109 It would be difficult to tell a supervisor I did not want to add them (to a social networking site) because I do not want them to think I have something to hide, but at the same time I want to keep my private life separate from my professional life. I’m not sure who I would talk to about it. Another reported, I have found that it is not unusual for supervisors/supervisees to be “friends” on Facebook. Most people I know, depending on the level of comfort, will allow limited access to supervisors or other individuals that are considered “authority” (faculty). It just depends on the level of friendliness between supervisor and trainee. The power dimension in supervision is significant, just as it is in psychotherapy. If a supervisor asks a trainee to be a Facebook friend or asks to “Google” the trainee while sitting in a supervision session, the trainee may be in a difficult position of feeling coerced to consent. Kaslow et al. (2011) wrote about the difficulty that arises when trainees may expect a “zone of privacy,” when supervisors and trainers see online information as “fair game.” The current study suggests, at least regarding social networking, such a zone may not be generally expected by students. Intriguingly, if contacted via a social networking site by a supervisor, 22.9% would “think nothing of it at all,” and 12.1% actually report seeing it as “a sign of the strength of the relationship.” When it comes to seeking information actively, almost half of the current respondents have “Googled” their supervisors, whereas only 2.7% report that their supervisors have disclosed “Googling” them. It seems likely that most of these students have not told their supervisors of their activities. Research (Ladany & Hill, 1996) has found supervisees choose not to disclose a range of feelings and experiences to their supervisors, mostly by simply avoiding the topics. Similarly, supervisors may have “Googled” supervisees without disclosing. One participant in the current study commented, “A supervisor and professor have commented on my profile picture . . . so I know they searched for my name; however, they did not tell me that they searched for me.” Another participant wrote, “I was searched for by the supervisor of a practicum site I applied to. It made me uncomfortable and I was faced with whether or not to accept, and if I accepted, what information I should change.” Indeed, it seems the entire supervisory relationship may be impacted by the elephant in the room of who has “Googled” whom, with various permutations of the triadic relationship (supervisor, trainee, and client) in the mix. Limitations The above results and discussion should be considered in light of the study’s limitations. Ascertaining response rates or characteristics of those who chose to respond to the study invitation or to whom the invitation was ultimately sent is impossible. This limitation is significant in online research in general, as it is impossible to generalize results to a population given so many unknowns about the sample. Several results are consistent with previous findings, which may suggest a generalizable phenomenon. Other results may perhaps be best interpreted with caution, especially those results asking novel questions (e.g., supervision). The study’s two-wave approach may have had implications for the generalizability, as the majority of participants were from PsyD 110 ASAY AND LAL This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. programs. A major oversight of the current study was an inadvertent omission of age in the demographic section of the survey. Thus, the possibility exists of a skewed age range. A question about the year in training yielded results not easily categorized (with some including master’s training, previous graduate training, etc.), leaving questions about the impact of training unanswered. The survey itself was created for this study and its psychometric properties are unknown. Finally, this study failed to assess why participants “Googled” their clients and whether clients consented to Internet searches. This dimension of consent seems crucial, as the act of “Googling” itself may not necessarily be antitherapeutic or an invasion of privacy. Implications for Training and Future Research As Internet issues become ubiquitous, it is likely that the issues raised in this study—and more—will become regular part of personal life and professional practice. The practice of, as one psychotherapist put it, “social network abstinence” may become less desirable or feasible for psychologists (Scarton, 2010). Thus, training programs and supervisors have the responsibility to discuss emerging Internet issues with students, a practice that seems lacking from the current study’s results. The focus of these discussions should be on both the process and the content of training and psychotherapy and consider Internet discussions from the very beginning, prior to engagement in any clinical work. For example, we recommend that training programs and sites make their utilization of online information clear to applicants and trainees, perhaps like the model recently developed by Wester, Danforth, and Ollie (2013). Such clear delineation of policy not only communicates professional expectations to trainees, but it also models clear disclosure of such policies to clients as trainees meet with them. We also recommend that supervisors broach Internet issues at the start of the supervisory relationship, making it a routine part of initiation into the relationship and part of the supervisory contract. Again, much as with issues of multicultural competence, supervisors should utilize their ascribed power to model transparency, openness, and to communicate the importance of the issue. As for clinical work, Internet issues may become increasingly part of the content of clients’ presenting distress: bullying on Facebook, blog attacks, having misinformation widely available and ever present may bring new experiences of distress. One of the authors (PA) worked with a client who had a video of him posted online without his permission and was unable to have it removed. Knowing this was “out there” for all to see was deeply distressing and reminiscent of previous experiences of indignation, powerlessness, and violation. A quarter of the participants in the current study reported discussing social networking site issues with clients, with the clients’ initiating these discussions most of the time. Being more open to discussing these issues, asking routinely about Internet presence and problems with clients, and initiating discussions may help clients feel their psychotherapists have an Internet cultural competence regardless of their perception of digital savvy. We suggest that programs address trainees’ lack of comfort in making ethical decisions in this realm in the form of recurring ethical discussions and role plays. Again, we encourage supervisors to ask trainees routinely about Internet issues that may emerge in the course of psychotherapy. Programs and sites could add Internet issues to intake forms as well, communicating to clients their importance. Dr. Kolmes’ Internet consent form may also be a good guide for informed consent issues. Future work should build on the current study’s investigation of how students would react and think about social network contact to how they actually do and have reacted. Researchers could investigate whether ways of handling the issue are related to age, level of training, or other factors, and whether they change over time (especially with changing online privacy policies). Certainly the questions of supervisor behavior and attitudes need to be explored more thoroughly. At this point, it is unclear how often supervisors engage in online searches or contact, for what purposes, and whether trainees are informed before or after the fact. Also unclear is what supervisors are telling their trainees about such issues and how they are advising them to proceed in their professional and personal lives. Also, a next natural step would be assessing clients’ perceptions of privacy, the Internet, and online social networking in psychotherapy. 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H., Lehavot, K., & Knapp, S. (2009). Psychotherapist self-disclosure and transparency in the Internet age. Professional Psychology: Research and Practice, 40, 22–30. doi:10.1037/a0014745 Received March 3, 2013 Revision received November 25, 2013 Accepted December 8, 2013 䡲

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