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Clinical Ethics in a Digital World

Clinical Ethics in a Digital World. Randy N. Walton, Ph.D. Sarah W. Bisconer, Ph.D. Friday March 15, 2013 9:00 am until 11:30 pm. Training Objectives. Provide a brief overview of digital and social media platforms (e.g., Internet, Facebook, Twitter, e-mail) that may impact clinical practice

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Clinical Ethics in a Digital World

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  1. Clinical Ethics in a Digital World Randy N. Walton, Ph.D. Sarah W. Bisconer, Ph.D. Friday March 15, 2013 9:00 am until 11:30 pm

  2. Training Objectives • Provide a brief overview of digital and social media platforms (e.g., Internet, Facebook, Twitter, e-mail) that may impact clinical practice • Review existing practice guidelines for use of digital and social media in clinical practice • Present a model for applying existing ethical principles to digital and social media in clinical practice • Review and discuss challenging clinical questions and scenarios involving digital and social media

  3. Handouts in Packet • Guiding Principles and Digital Media • Key Definitions and Glossary • Sample Agency Policy • Sample Private Practice Policy • Email Guidelines • Email Discussion

  4. “Psychotherapists as a group have not been known to be highly adaptive or flexible. Many new ideas, approaches, and techniques are often met with resistance and skepticism. In spite of the token commitment to individual differences and cultural diversity, [clinicians] often fail to acknowledge or say ‘This is foreign to me’, ‘I don’t understand’, or ‘I am intimidated’ but instead often say ‘It is inappropriate and unethical’”. Zur, O. (2012) TelePsychology or TeleMentalHealth in the Digital Age: The Future is Here. California Psychologist, 45/1, p. 14. In general, would you say this statement is: True False As applied to you, would you say this statement is: True False Context Questions

  5. Context Question: Better-Worse vs. Advantages-DisadvantagesWhich of these advantages and disadvantages are relevant in psychotherapy? In-person Relationships** Cyberspace Relationships* Better More real/Less superficial Primarily two senses Virtual interactive physical activities Limited non-verbal/pre-verbal More intimate More connected Not limited by physical proximity CSR due to fear/awkwardness in IPR Healthier Unhealthier *Invokes place and spatial interaction (CSR) • Better • More real/Less superficial • All five senses • In-person interactive kinesthetic activities • Non-verbal/pre-verbal communication • More intimate • More connected • Limited by physical proximity • Isolation/withdrawal due to fear/awkwardness in IPR • Healthier • Unhealthier **Invokes physical presence (IPR)

  6. Challenges in Developing and Using Ethical Guidelines • In clinical practice, the proliferation of digital media in society requires a significant shift in ethical thinking and practice to help clinicians: • Identify potential ethical dilemmas and concerns • Identify relevant existing ethical principles • Identify applicable existing ethical guidelines • Appropriately apply, extrapolate, and modify existing principles and guidelines

  7. Practical Use of Ethics Codes Ethics codes cannot do our questioning, thinking, feeling, and responding for us. Such codes can never be a substitute for the active process by which the individual therapist or counselor struggles with the sometimes bewildering, always unique constellation of questions, responsibilities, contexts, and competing demands of helping another person. Ethics must be practical. Clinicians confront an almost unimaginable diversity of situations, each with its own shifting questions, demands, and responsibilities. Every clinician is unique in important ways. Every client is unique in important ways. Ethics that are out of touch with the practical realities of clinical work, with the diversity and constantly changing nature of the Therapeutic venture, are useless. (Pope & Vasquez, 1998, xiii–xiv) Kaslow, F., Patterson, T., & Gottlieb, M. (2011). Ethical dilemmas in psychologists accessing internet data: Is it justified? Professional Psychology: Research and Practice, 42, 105-112.

  8. Purposes of and Challenges toProfessional Ethical Codes • Codes of ethics are designed to benefit the client, protect the client, and protect the integrity of the therapeutic process. • The development of codes of ethics is generally delayed and reactive to changing social norms, practices, and the innovations brought about by emerging technologies. • The use and rapidly evolving technology associated with digital media are new enough that there are currently no broadly accepted guidelines regarding how digital media can or should be used ethically in behavioral health

  9. Professional Codes of Ethics • Current ethical codes offer limited or no specific guidelines for clinicians’ use of digital technology: • ACA • A.12 – Focuses on multiple uses of technology, but no information specifically addresses counselor’s use of social networking • AAMFT, APA, NASW • Discuss universal concepts such as “dual or multiple relationships” and “client’s right to privacy”, but nothing specifically on clinicians’ use of digital technology or social networking

  10. Other Guidance RegardingClinical Use of Digital Technology • Ohio Psychological Association (2010): http://www.ohpsych.org/psychologists/files/2011/06/OPATelepsychologyGuidelines41710.pdf • National Association of Social Workers and Association of Social Work Boards - Standards for Technology and Social Work Practice: http://www.aswb.org/pdfs/TechnologySWPractice.pdf • Canadian Psychological Association – Providing Psychological Services via Electronic Media: http://www.cpa.ca/aboutcpa/committees/ethics/psychserviceselectronically/ • American Telemedicine Association - Practice Guidelines for Videoconferencing-Based Telemental Health: http://www.americantelemed.org/docs/default-source/standards/practice-guidelines-for-videoconferencing-based-telemental-health.pdf?sfvrsn=6 • American Telemedicine Association – Evidence Based Practice for Telementalhealth: http://www.americantelemed.org/docs/default-source/standards/evidence-based-practice-for-telemental-health.pdf?sfvrsn=4 • International Society for Mental Health Online - Suggested Principles for the Online Provision of Mental Health Services: http://www.ismho.org/suggestions.asp For a more comprehensive list of available guidelines see: Pope, K. Ethical Standards & Practice Guidelines for Assessment, Therapy, Counseling, & Forensic Practice. http://kspope.com/ethcodes/index.php

  11. Ethical Principles • Principle-based Ethics is based on a commitment to five overarching, common, basic prima facie moral principles: • Beneficence: Responsibility to do good and promote others’ welfare • Nonmaleficence: Obligation to do no harm or act in ways that have a high risk of harming others • Autonomy: Support others’ informed, non-coerced freedom of thought and action; promote independence • Fidelity: Be faithful to commitments and promises, do not deceive or exploit, be trustworthy • Justice: Act fairly or justly, especially balancing rights and interests of clients and others; afford all individuals the opportunity for equal access to the same high-quality treatment

  12. Vignette It’s 10:00 on a Friday night. A child psychologist sits at her home computer checking Facebook updates and thinking about upcoming weekend plans. Distracted by thoughts about a particularly intense session that afternoon with a teenage client, wherein he’d disclosed some distressing recent peer interactions, she decides on a whim to try to view his Facebook page. She finds it easily, set up without privacy restrictions, and is troubled when she reads his latest status update: “I’m going to sleep now . . . See you all on the other side.” The psychologist continues to read back through her client’s Facebook wall and is horrified to find a series of taunting and harsh comments left by some of the client’s “friends” over the past few weeks. After viewing this disturbing content for a short while, the clinician feels uncertain about her professional obligation and worriedly wonders what she should do to help ensure her client’s safety. From: Rachel A. Tunick, Lauren Mednick, and Caitlin Conroy (2011). A Snapshot of Child Psychologists’ Social Media Activity: Professional and Ethical Practice Implications and Recommendations. Professional Psychology: Research and Practice, 42. 440.

  13. Major Ethical Issues in a Digital World • Informed Consent • Boundaries • Dual/multiple relationships • Therapist self-disclosure • Confidentiality The following slides briefly consider these issues in a non-digital context

  14. Informed Consent: Factors to consider • Assess Competence: Before engaging in the remote delivery of mental health services via electronic means, practitioners should carefully assess their competence to offer the particular services and consider the limitations of efficacy and effectiveness that may be a function of remote delivery. • Check Liability Insurance: Practitioners should consult with their professional liability insurance carrier to ascertain whether the planned services will be covered. Ideally, a written confirmation from a representative of the carrier should be obtained. • Seek Consultation: Practitioners are advised to seek consultation from colleagues and to provide all clients with clear written guidelines regarding planned emergency practices (e.g., suicide risk situations). • Develop Written Plan: Because no uniform standards of practice exist at this time, thoughtful written plans that reflect careful consultation with colleagues may suffice to document thoughtful professionalism in the event of an adverse incident. • Cite Confidentiality Limitations: A careful statement on limitations of confidentiality should be developed and provided to clients at the start of the professional relationship. The statement should inform clients of the standard limitations (e.g., child abuse reporting mandates), any state-specific requirements, and cautions about privacy problems with broadcast conversations (e.g., overheard wireless phone conversations or captured Internet transmissions). • Specify Services Offered: Clinicians should thoroughly inform clients of what they can expect in terms of services offered, unavailable services (e.g., emergency or psychopharmacology coverage), access to the practitioner, emergency coverage, and similar issues. • Clarify Billing for Services: If third parties are billed for services offered via electronic means, practitioners must clearly indicate that fact on billing forms. If a third-party payer who is unsupportive of electronic service delivery is wrongly led to believe that the services took place in vivo as opposed to on-line, fraud charges may ultimately be filed. Koocher, G., & Morray, E. (2000). Regulation of telepsychology: A survey of state attorneys general. Professional Psychology: Research and Practice, 31, 503-508.

  15. Informed Consent: Additional Factors to Consider • “Several critical issues need to be addressed: Many technologies are powerful but fragile; crucial information can be lost or intercepted; not all Web sites providing information are reliable; service providers can easily misrepresent themselves and their credentials online; confidentiality in an electronic medium can quickly evaporate; jurisdiction, liability and malpractice issues blur when state lines and national boundaries are crossed electronically; numerous digital divides can thwart access and success; and clients and social workers alike may have unrealistic expectations for what a technology can actually provide.” NASW and Association of Social Work Boards Standards for Technology and Social Work Practice. http://www.aswb.org/pdfs/TechnologySWPractice.pdf p.6 For a sample Social Media Policy available for download and use, see Handouts or: K. Kolmes - Social Media Policy: http://drkkolmes.com/for-clinicians/social-media-policy/

  16. Dual Relationships and Therapist Self Disclosure Boundaries are addressed in all professional ethics codes • Dual/multiple relationships and therapist self-disclosure • Involve at least Boundary crossing • Possibly involve Boundary violation • “Boundary violations” are clearly unethical and must be avoided. • “Boundary crossings” are inevitable and must be monitored, managed, and deliberate when possible. • Boundary crossings can be important and appropriate to enhance therapeutic effectiveness. • In some situations it may be violating ethical principle of Beneficence to not cross a boundary if it would benefit a client. Zur, O. (2009). Therapeutic boundaries and effective therapy: Exploring the relationships. In W. Donohue & S. Graybar (Eds.), Handbook of contemporary psychotherapy: Toward an improved understanding of effective psychotherapy (pp. 341-357). Thousand Oaks, CA: Sage. Zur, O., Williams, M., Lehavot, K., & Knapp, S. (2009). Psychotherapist self-disclosure and transparency in the internet age. Professional Psychology: Research and Practice, 40, 22-30.

  17. Dual Relationships: Boundaries • Boundaries: “a flexible set of conditions that…establish rules and role expectations that the patient may rely upon for the safety required for treatment” • Glass, L. L. (2003). The gray areas of boundary crossings and violations. American Journal of Psychotherapy, 57, 429. • No longer inflexible prohibitions derived from strict analytic and risk management rules, e.g., “Never touch your client”, “Never give or accept gifts” • The 2005 ACA Code of Ethics regarding potentially beneficial boundary crossings: • "Examples of potentially beneficial interactions include, but are not limited to, attending a formal ceremony (e.g., a wedding/commitment ceremony or graduation); purchasing a service or product provided by a client or former client (excepting unrestricted bartering); hospital visits to an ill family member; mutual membership in a professional association, organization, or community.” • American Counseling Association. (2005). ACA code of ethics. Alexandria, VA: American Counseling Association.

  18. Confidentiality • Confidentiality issues will be discussed in relation to various digital media platforms • Keely Kolmes, Psy.D. addresses limits of confidentiality in her Private Practice Social Media Policy and on her website. • Issues of confidentiality in specific situations are also addressed at her website • http://drkkolmes.com/for-clinicians/articles/

  19. Clinical Ethics in a Digital WorldSummary and Overview • There are no current widely accepted guidelines regarding clinical use of digital technology • Therapists must combine and apply their knowledge of: • Digital technology currently available/in use • We will review: Digital terms and digital platforms in use • Developing guidelines for clinical use of digital technology • We will review: Clinical uses of these digital platforms • Existing principles and accepted guidelines • We will consider: Ethical issues and concerns that may arise • Clinical experience • We will present: Ideas and facilitate discussion to address ethical issues and concerns

  20. Ethics and Cultural Competence in a Digital World • Cultural competence refers to an ability to understand, communicate with, and effectively interact with people across cultures. • Cultural competence comprises four components: (a) awareness of one's own cultural worldview, (b) attitude towards cultural differences, (c) knowledge of different cultural practices and worldviews, and (d) cross-cultural or multicultural skills. • Consider your responses to the Context Questions regarding therapist’s flexibility, ability to adapt, and commitment to cultural diversity. • The concepts of “digital natives” and “digital immigrants” provides a helpful cultural context for ethical decision-making in a digital world.

  21. Digital Natives • Generation X - Born in the early 1960's through the early 1980's, Gen X encompasses 44 to 50 million Americans. Members of Generation X are largely in their 30’s and 40’s. On the whole, they are more ethnically diverse and better educated than Baby Boomers. The first generation to grow up with computers, technology is woven into their lives. They adapt well to change, are tolerant of alternative lifestyles, and often "work to live rather than live to work". They appreciate fun in the workplace and espouse a work hard/play hard mentality. • Generation Y - Born in the early 1980's through early 2000's, Generation Y (or the Millennial Generation or Eco-boomers) encompasses 70 to 80 million Americans, and is often sub-divided by age (adults, teens, tweens). Generation Y grew up with technology and takes it for granted. They are typically tech-savvy and often connected via smart phones, tablets, laptops, and other digital media platforms 24/7. Many in this generation prefer to communicate through social media, email, text messaging, and digital media platforms rather than face-to-face contact. • Post Gen Y

  22. Digital Immigrants • Baby Boomers - Born during the post WWII baby boom between the years 1943 and the early 1960's, Baby Boomers number around 80 million in the U.S. Baby Boomers are often associated with a rejection or redefinition of traditional values, with a general cynicism and distrust of government. Baby boomers found that their music, most notably rock and roll, was another expression of their generational identity. Baby boomers comprised the first generation to grow up with television, telephones, and portable (transistor) radios, and technologically sophisticated analog (as opposed to digital) devices. • Pre-Baby Boomer

  23. Terms to Facilitate Cultural Competence • What is digital technology? • Technology used by devices such as computers, cell phones, TV, etc. • Information represented digitally (i.e., using digits) instead of analogically, which allows much higher data volume and accuracy. • What is the Internet? • A global network of interconnected computer networks. • “Net for Beginners” • Wikipedia Internet entry • What is the Web or World Wide Web (www)? • A system of interlinked hypertext documents accessed via the Internet. With a web browser, one can view web pages that may contain text, images, videos, and other multimedia, and navigate between them via hyperlinks. • Wikipedia World Wide Web entry • What is a web browser? • A software program for retrieving and presenting information resources on the Web. • Internet Explorer (default browser with Microsoft Windows OS), Firefox (open source alternative to IE). • What is a Search Engine? • A program that searches Web documents for specified keywords and returns a list of the documents where the keywords were found. • Google, Bing, Yahoo.com, Ask.com, DuckDuckGo, Dogpile

  24. Terms to Facilitate Cultural Competence • What is social media? • A broad term covering diverse types of digital media websites which do not just provide information. A common link between these websites is the ability to interact with the website and interact with other visitors, hence , “social” media. • What is a blog? • A personal journal posted on the Web for public viewing. Includes text, can include multimedia, and often links to other blogs or websites. May be primarily informational, may involve discussion (at which point it is a social media site) and sometimes called a weblog. • What is TeleMentalHealth? • The use of digital technology, usually interactive, 2-way audio and video, to provide mental health services between individuals who are not physically located in the same place. In addition to direct mental health care/psychotherapy, may include continuing education and consultation. Sometimes called telehealth, telepsychiatry, telemedicine, telepsychology, or e-health • What is texting? • Typing and sending a brief, electronic message between two or more cell phones or other digital devices over a network. Sometimes called text messaging. • What is e-mail? • A method of exchanging text-based messages from an author to one or more recipients via digital devices (e.g., computers or cell phones).

  25. Digital Technology Platforms and Issues Relevant to Clinicians Focus on five types of digital technology platforms • Internet • Social Media (including blogs) • TeleMentalHealth • Texting • E-mail For each platform • Potential uses • Advantages and concerns/disadvantages • Potential therapist-client interactions/relationships and associated clinical and ethical considerations

  26. The Internet: Potential Clinical Uses • Source of education/information • Adjunct resource for in-person therapy • Therapist seeks/discovers client information • Client seeks/discovers therapist information • Alternatives to in-person therapy, e.g., Online-Therapy, FearFighter

  27. Therapist Accessing Client Internet Data • Digital Immigrants and Natives have typically heard that “nothing on the Internet is private.” • Undisclosed or unauthorized Internet searches may not be illegal or violate specific ethical guidelines. • However, if therapist assumes the right to seek such information, may violate principles of Autonomy, Justice, Fidelity. • May also violate Principles of Beneficence and Non-maleficence if client feels trust has been violated and drops out of treatment, etc. • Digital Immigrants may not have concerns about a therapist seeking information about them without explicit consent. • However, it is the therapist’s responsibility to understand and uphold ethical practices, not the client’s.

  28. Therapist Accessing Client Internet DataClient Privacy • Clients have the right to control information sharing with the therapist • Awareness of information therapist possesses – Facilitates safe, trusting relationship • Types of information - Demonstrating perceptions of the relevance of the shared information with presenting problems and treatment goals • Amount of information - Testing the therapist’s ability to receive and process information; monitoring therapist reaction to information • Timing of sharing - Perceived trust of the therapeutic relationship; reflection of client readiness to change Kaslow, F., Patterson, T., & Gottlieb, M. (2011). Ethical dilemmas in psychologists accessing internet data: Is it justified? Professional Psychology: Research and Practice, 42, 105-112.

  29. Therapist Accessing Client Internet Data Informed Consent • Obtaining client Informed Consent about therapist practices regarding Internet searches for client information is strongly recommended (Principle of Autonomy). • Internet searches without informed consent sometimes appropriate under duty to protect statutes/regulations, client incapacity, etc. (Principles of Non-maleficence and Justice trump Autonomy). • With client’s prior informed consent, therapist on more solid ethical ground in either situation.

  30. Informed Consent: Reflects Therapist Practice and Perspectives • Within sound clinical and ethical boundaries there can be different approaches to a therapist accessing client information: • “At times I may Google my clients before the beginning of psychotherapy or during psychotherapy. If you have concerns or questions about this practice, please discuss them with me.” • “I neither search for clients on Internet search engines such as Google, nor search my clients' social networking profiles such as Facebook, unless there is an acute crisis which involves safety issues.” • “While my present or potential clients might conduct online searches regarding my practice and/or me, I do not search my clients via search engines or social networking sites such as Google, YouTube, or Facebook. If clients ask me to conduct searches or review their websites or profiles, and I assess that it might be helpful, I will consider it.” • Zur, O. Digital Ethics 101: To Google or not to Google Our Clients? Retrieved from http://www.zurinstitute.com/digital_ethics_clinicalupdate.html/

  31. Therapist Accessing Client Internet Data Intentional vs. Accidental • Digital scenario: • Therapist inadvertently discovers troubling client behavior on social networking site, blog, sex offender registry, police blotter, etc. • Non-digital analog: • Therapist sees inebriated client at a public gathering by happenstance; client has claimed abstinence • Digital scenario: • Therapist reading client’s blog entry during session with client, at client’s request, discovers troubling information about another client • Non-digital analog: • Spouse in couple’s therapy reveals secret about a client without client’s consent

  32. Therapist Accessing Client Internet Data Intentional vs. Accidental Discussion • No inherent ethical issues in these situations. Therapist did not intentionallyseek information without client consent. In first digital and non-digital scenarios, no reasonable expectation of privacy (although people often demonstrate poor judgment about this). However, clear clinical issues in these situations that can raise ethical issues. It is essential for therapist to determine how to handle such information consistent with Principles of Beneficence and Fidelity.

  33. Client Access to Information About Therapist Therapist Self-Disclosure: Revelation of personal rather than professional information • Deliberate – Information a therapist chooses to share • Example: Verbal disclosure of personal information, nonverbal disclosure ( e.g., displaying personal photos or affective reactions to client information) • Self-revealing (therapist information) and self-involving (therapist personal reactions) • Designed to enhance effectiveness of treatment, benefit client • Unavoidable – therapist “disclosure that is neither deliberate nor avoidable … [information shared that is] part of everyday life” (p. 23) • Example: Gender, age, personal appearance, office location and décor, time off • Accidental/Inadvertent – Information therapist inadvertently shares when inadvertently overlooking or ignoring safeguards • Example: Unplanned encounters in a public venue, spontaneous verbal or non-verbal responses to client information Zur, O., Williams, M., Lehavot, K., & Knapp, S. (2009). Psychotherapist self-disclosure and transparency in the internet age. Professional Psychology: Research and Practice, 40, 22-30.

  34. Client Access to Therapist Internet Data • Digital Technology: More difficult for therapist to control information sharing (i.e., to deliberately share information): • Clients “Google” therapist • Online evaluations and complaints (yelp.com, healthgrades.com, manta.com, complaintsboard.com) • Social network (Facebook, MySpace, LinkedIn) • Licensing Board information • Therapists cannot control all information available about them • Accept, manage, embrace, take advantage of the digital technology that makes the information available

  35. Client Accessing Therapist Internet Data • Curiosity APPROPRIATE • Simple Internet search (e.g., Google, Bing) • Done by most people before going to therapist • Due Diligence • More thorough: Search engines plus social media, licensing boards, ratings sites • Not unusual, healthy, often encouraged • Intrusive • “Lurking” in professional sites, chatrooms, listserv without therapist knowledge • Deceitful • Client using false identity to interact in social media sites, chatrooms, etc. • Illegal and Cyber-stalking • Pay to obtain extensive personal information (typically $15 - $60) • Type name in search engines and ads often appear on right side of page INAPPROPRIATE Zur, O. “Digital Ethics and online boundaries”. http://zurinstitute.com/videos/zur_evms.html

  36. Client Accessing Therapist Internet Data:Managing Therapist Internet Disclosures • Expect and encourage informed consumers to do “simple” or “more thorough” searches • Be careful about anythingyou post on websites, social media, blogs, chatrooms, etc. - Remember: everything posted online remains indefinitely and anything posted online is potentially available for anyone to view • Separate professional and personal information (privacy settings, passwords, etc.) • Search yourself regularly using various name combinations • Sign up for Google alerts (www.google.com/alerts) • Carefully evaluate your response to negative postings Zur, O. “Digital Ethics and online boundaries”. http://zurinstitute.com/videos/zur_evms.html

  37. Managing Therapist Internet Disclosures Negative Postings About You • Do not panic or react impulsively • Carefully evaluate your options (some options listed below) • Consult with colleagues and/or experts • ORM (Online Reputation Management) (e.g., www.reputation.com) • Ask site to remove the negative posting (some will, some will not) • Ask colleagues to write honest positive information on the site • Do not post a rebuttal or criticism (confidentiality, inflammatory) • Establish a positive web presence (preponderance of Internet information about you is accurate and deliberate)

  38. Description and Examples of Social Media For helpful descriptions of various social media platforms (and the source of the graphic above), see “The Immense Guide to Social Media Sites 2013” : http://www.ideasbynet.com/blog/the-immense-guide-to-social-media-sites/ Select slide information obtained from Macchi, C. R., & Ingram, J. (2011). Ethical issues of therapists’ involvement in social networking. Retrieved from http://www.slideshare.net/crmacchi/ethical-issues-of-social-networking-10-11-11-10542241.

  39. Description of Social Media • A broad term covering diverse types of digital media websites which do not just provide information. • A common link between these websites is the ability to interact with the website and interact with other visitors • Facilitates connecting and communicating among diverse groups, or individuals with common interests

  40. Social Media: Categories Networking Facebook: maintain personal connection with friends and family Twitter: follow relevant people within your area of interest, more relaxed than LinkedIn LinkedIn: primary professional network, online CV Google+: newest of social networking platforms, tries to combine best of Twitter and Facebook MySpace: Discover, share and connect to music from the world's largest streaming library.

  41. Social Media: Categories • Support and Health Information Sharing • Use search engine, type “[problem or disorder] support group online” • Depression: About.com – Depression, DepressionTribe.com • Anxiety: findthelight.com, PsychCentral – Anxiety • Sexual Abuse: Pandora’s Project, sexual abuse support groups • PTSD: PTSD support groups, National Center for PTSD

  42. Social Media: Categories • Discovery • Pinterest: online pin board, “pin” visual content • StumbleUpon: go to random website, blog, image or video aligned with your chosen interests • Delicious: catalog and organize online bookmarks/hyperlinks, resources 

  43. Social Media: Categories • Showcase • YouTube: most popular (4B hits/day) video sharing site, entertainment and education (similar: Vimeo, Metacafe) • MySpace: entertainers and fans, especially music, connect and showcase (similar: Soundcloud, Mixcloud) • Pinterest: exhibit work/products visually (similar: Piccsy) • Blogs: Tumblr, WordPress • Webinars

  44. Social Media: Categories • Q & A Sites • Quora: contribute answers/questions, can establish expertise, “best” answers, not all answers • StackExchange: network of specialist Q&A sites, profile page allows posting your Q’s and A’s • Yahoo! Answers: widespread use, lacks social dimensions/community controls • Webinars

  45. Social Media: Categories • Social News • Digg: keep abreast of breaking news across the internet, submit interesting content • Reddit: news submitted and recommended by users, can start topic with a question • Technorati: a leading search engine for blogs • Buzzfeed, Alltop, Fark

  46. Clients’ Use of Social Media • Clients are increasingly using social media to access health-related resources and become better-informed consumers • Types of social media most often used involve support groups: • Blogs • Chat rooms • Message boards • Online communities • Patient testimonials • “New technology is empowering patients and enabling them to be much more assertive and health-care professionals have to spend more time helping them to sift through what might or might not be helpful online.” (Neil Coulson, a chartered psychologist at the University of Nottingham, UK, p. 1142) Devi, S. (2011). Facebook friend request from a patient? Lancet Medical Journal, 33, 1141-1142. Retrieved from http://www.facebook.com/TheLancetMedicalJournal.

  47. General Ethical Issues Associated with Social Media • Client confidentiality – privacy of information • client controls the timing, types, amounts, and ways personal information is shared with the therapist • clinicians use reasonable safeguards to protect PHI from unintended or unauthorized disclosures or uses (HIPAA Privacy Rule) • Client confidentiality – security of information • Clinicians prevent unintended or malicious disclosure, alteration, or loss of PHI • Therapist self-disclosure and transparency • Therapist manages personal information shared or available to client • Dual relationships • Therapist enters into relationship with client outside of therapy relationship Taylor, L., McMinn, M., Bufford, R., & Chang, K. (2010). Psychologists attitudes and ethical concerns regarding the use of social networking web sites. Professional Psychology: Research and Practice, 41, 153-159. Zur, O., Williams, M., Lehavot, K., & Knapp, S. (2009). Psychotherapist self-disclosure and transparency in the internet age. Professional Psychology: Research and Practice, 40, 22-30.

  48. Specific Issues: Ethical Principles - Therapist Accessing Client Information Via Social Networking Sites • Autonomy, Fidelity: Disrupts the client’s control of personal information and the pacing of treatment • Therapist views information on FB page that appears to be relevant to the therapeutic work that the client has not yet revealed • Autonomy, Fidelity, Justice: Therapist becomes a “secret-holder” • Client working on extra-marital affair is pictured with the paramour on his FB page while his partner remains unaware • Autonomy, Fidelity: Therapist becomes an investigator verifying client information • Client reports about having written books and attending certain schools while the internet reveals no information • Autonomy, Fidelity: Therapist must manage conflicting or contradictory information • Client describes she has been sober for three months. A picture on FB shows her holding a drink at a recent party Kaslow, F., Patterson, T., & Gottlieb, M. (2011). Ethical dilemmas in psychologists accessing internet data: Is it justified? Professional Psychology: Research and Practice, 42, 105-112.

  49. Specific Issues: Ethical Problems - Facebook “Friend” Request from a Client • Dual Relationship: Altering client’s perception of the therapeutic relationship • Client learns about therapist’s political and social views/activities, family and friends, listed on profile • Client interacts with therapist like other Facebook “friends • Blurred Boundaries: Client develops an expectation that contacting the therapist outside of therapy is acceptable and even invited • Client is “invited” into clinician's personal life • Client posts questions that should be addressed in therapy on the therapist’s wall • Confidentiality: Client sees list of therapist’s “friends”, wonders which others may be clients Kaslow, F., Patterson, T., & Gottlieb, M. (2011). Ethical dilemmas in psychologists accessing internet data: Is it justified? Professional Psychology: Research and Practice, 42, 105-112. Devi, S. (2011). Facebook friend request from a patient? Lancet Medical Journal, 33, 1141-1142. Retrieved from http://www.facebook.com/TheLancetMedicalJournal. Therapist’s approach to “friend” requests should be explicitly covered in Informed Consent

  50. Specific Issues: Potential Problems Related to Subtleties of Digital Technology • If e-mail account used to create Twitter account is used to e-mail a client (e.g., to change an appointment time), when client looks for "friends" on the Twitter site you are likely to be on the list and vice versa.; however, therapists should be mindful of unavoidable and accidental forms of self-disclosure that may affect others’ perceptions and the therapy process • Relatives or friends of clients may follow our professional social media postings and express strong reactions to client. Client may feel protective, defensive, or uncomfortable • If clients become “Fans” or “like” clinician's professional Facebook page, this may raise confidentiality concerns, e.g., which other Fans may also be clients • If clients become “Fans” or “like” clinician's professional Facebook page, this may be considered a passive request for a client testimonial, which is forbidden in ethics codes • If family members and friends become “Fans” or “like” the page, clients will have access to this information • If clinician posts at 2:00 AM, is this indirectly revealing information about clinician’s personal schedule and habits and how might it affect clients who notice? • Friends or colleagues may post well-meaning comments on clinician's Facebook wall which might be too personal for clinician's comfort • You are meeting with a client addressing a certain issue. Later that day, the client views your Facebook page where you have provided a link to information related to their issue; client believes the post is about him/her

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