Social media and social network developments

Within the landscape of technological developments, the innovation of social media platforms or Web 2.0-bascd technology (c.g. Facebook, YouTube, Linkc-dln, Twitter, Second Life) has profoundly impacted upon global social communication. ‘Ubiquitous’ and ‘proliferation’ appear to be the most common words used to describe the exponential growth of social media usage, recently accelerated by mobile communication technologies (c.g. Smartphones). Web 2.0 technology is generally understood as a medium that facilitates user-generated content and promotes bi-directional and participatory communication rather than the passive observing of information as presented by Web 1.0 options (Anderson, 2007).

With reference to social media, Hansen, Shneiderman and Smith (2011: 12) offer the following broad definition and suggest that social media is;

... a catchall phrase intended to describe the many online sociotechnical systems that had emerged in recent years, including services like email, discussion forums, blogs, microblogs, texting, chat, social networking sites, wikis, photo and video sharing sites, reviews sites and multigaming communities.

Each social media platform has unique features within social network sites, facilitating users to create an online identity and develop a network of connections with other individuals with whom they interact to build communities or networks (Boyd & Ellison, 2007). The terms ‘friend’, ‘fan’ and ‘follower’ as used in social networks are interesting to consider in terms of social influence. In a study investigating the perceived trustworthiness of health information disseminated via a micro-blog (i.c. Twitter - a social media network that allows members to post short messages of 140 characters) the information was considered more reliable if it was sent by a professional who had many ‘followers’ (Lee & Sundar, 2013). The following vignette illustrates this point in a therapy setting.

Vignette I

Hilary is an experienced therapist and maintains a popular stress management psycho-educational micro-blog. One of her ‘followers’ contacts Hilary via the social network to make a therapy appointment. At the first session, the client comments that considering the number of followers that Hilary has on the social network, she must be a ‘brilliant therapist’. The client adds ‘I really didn't think I'd be able to get an appointment with you so quickly ... I feel like I'm talking to a celebrity!’

Social media use in counselling and psychotherapy

Increasingly, practitioners are using social media in a professional capacity to participate in professional peer support networks and promote their clinical services on social network sites (Kolmes and Taube, 2016). Practitioners arc embracing a variety of social media technology to deliver psycho-education (Giota & Klcftaras, 2014), provide and receive clinical supervision (Jcncius & Baltrinic, 2015), and recruit research participants, especially with difficult to access populations (King ct al., 2014).

However, it appears that many practitioners hold ethical concerns about providing therapeutic services or communicating with clients via social media sites due to the associated risks of compromising client confidentiality, privacy and professional boundaries (Giota & Klcftaras, 2014). For example, the issue of receiving a ‘friend request’ or ‘out of office’ contact request from a client via a social network highlights these risks and the acceptance or rejection of such requests requires critical reflection on the clinical, ethical and legal implications (Zur, 2015). From a technology perspective, the security risks inherent in many websites and communication systems compound these concerns (Kaplan et al., 2011).

Of further concern is how practitioners can keep their personal engagement in social networks separate from their professional role and if such a separation is realistic in the digital age (Lannin & Scott, 2013). Clients frequently search online for information about their therapist and whether or not the therapist maintains a deliberate social media presence; generally, much information is available in this public domain (Zur, 2008). In their survey of therapy clients (N = 332) who had sought personal information about a therapist online, Kolmes and Taube (2016) reported that 69.9% of their participants were successful in this attempt. The foremost domains of personal data discovered related to the therapist’s age, education, home address, photographs, family and relationship information. Curiosity was cited as the main reason for conducting these searches and almost 75% of participants did not disclose the search to their therapist. In the context of therapist safety and client care, Zur (2008) recommends that therapists assume that their clients will read anything that they post online and advises that therapists should conduct an online search of their name to establish what information is readily accessible to clients.

Lannin and Scott (2013: 135) draw a useful comparison between social networking ethics and what they term ‘small world ethics’ pertaining to practitioners working in small rural communities and suggest that similar ethical issues can arise in both contexts. They recommend that practitioners remain mindful of the increased likelihood of encountering ethical challenges in the ‘small world’ of social networks. Different media sites warrant different levels of vigilance in assessing potential challenges to ethical practice. Whilst beyond the scope of this chapter to discuss the range of social media tools and virtual platforms, a number of ethical principles may be discussed as relevant to all such online communications. The key recurring themes in the literature refer to the establishment and maintenance of professional boundaries, privacy, confidentiality and informed consent.

Boundaries of professional practice: therapist self-disclosure

Associated with professional boundaries, therapist deliberate self-disclosure has been a widely debated concept in psychological therapy. Although individual differences exist among therapists and self-disclosure is frequently influenced by theoretical orientation (Ziv-Beiman, 2013), Hcnrctty and Levitt (2010), recommend that therapists view self-disclosure as an empirically supported intervention, albeit one to be used judiciously, and provide practice guidelines to evaluate the therapeutic legitimacy of this intervention. They recommend that therapists deeply reflect on the reasons for the disclosure and assess its appropriateness for the individual client with due regard to cultural diversity. The authors further advise deliberation on the content, timing and manner by which the disclosure will be communicated. The nature of the therapist’s disclosure is also of relevance evaluating this intervention. Ziv-Beiman (2013: 63) distinguishes between ‘immediate’ (in the moment reactions to the client or the therapeutic process or relationship) self-disclosure by the therapist and ‘non-immediate’ (disclosure relating to the therapist’s personal life outside of the therapeutic frame) with appropriate immediate disclosure appearing to positively impact on therapy outcomes.

According to Zur et al. (2009), digital developments challenge our conceptions of therapist self-disclosure in contemporary clinical practice. The authors distinguish between appropriate disclosures that arc clinically beneficial to the client and disclosures that are inappropriate and which may serve the needs of the therapist rather than those of the client. This is relatively clear within the boundaries of the therapy room but less so when considering the implications of therapists actively engaging with social media where self-disclosure is practically unavoidable, not necessarily immediate and frequently unintended (Zur, 2008). As suggested by Taylor ct al. (2010: 157) ‘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’. The following example demonstrates a spontaneous disclosure with clear ethical and clinical implications, however inadvertently or perhaps naively made.

Vignette 2

Sarah is a trainee therapist and has recently commenced her first placement in a public health service setting. Sarah maintains an online presence via a social media site (e.g., Facebook). In a recent encounter with a client, Sarah was deeply moved by the session. Later she posted the following: ‘My 3 o'clock today was SO inspirational!! This young lady has navigated the extremes of trauma. Much for me to learn.’

Subsequently, Sarah regretted the post and contacted her supervisor to discuss the situation.

Privacy, confidentiality and informed consent in social media use

Client privacy and confidentiality arc fundamental to the ethical practice and integrity of psychological therapy and clear guidelines are presented in all professional codes of ethics to this effect. While there arc limits to confidentiality in cases of risk every effort is made by practitioners to protect client privacy and confidentiality for legal as well as ethical and clinical reasons (Jenkins, 2017). As social media engagement is exercised in a public domain, the potential exists for any information generated in that environment to be permanently discoverable even after an account has been deleted (Giota & Kleftaras, 2014). Moreover, clients may not be aware of the public nature of the information they disclose or that contacting their therapist in a public forum may breach their own privacy and confidentiality (Zur, 2010). Vignette 3 illustrates client confidentiality and privacy being compromised in an online professional forum. Increasingly, listservs (mailing list server where mass emails arc circulated to members) arc being used for professional consultation and referral, although they may be vulnerable to unauthorised access (Collins, 2007).

Vignette 3

Daniel, an experienced therapist, has been working with Anya, who is now relocating to another part of the country. Anya asked Daniel if he could recommend a therapist in that area. Daniel agreed to seek a referral and posted the following message on his professional listserv; ‘Seeking a Spanish speaking therapist in the Stevenage area with expertise in anxiety disorders for female client (mid 20's) who is relocating shortly’. Daniel did not disclose to Anya that he sought the referral online or discuss the implications of this.

Several authors have discussed therapists conducting online searches of their clients (see below) and such ‘outside of office’ information seeking is assessed by Zur (2010: 145) as ‘uncharted clinical, ethical and legal territory’. In terms of ethical decision making in this regard, DiLillo and Gale (2011) recommend Clinton and colleagues’ (2010) framework as a useful resource to determine the rationale for conducting such a search and to critically reflect on the clinical implications, issues of informed consent, decisions about sharing the information with the client and record keeping of the search.

In a study with graduate psychology students (N = 854) regarding their attitudes towards and their actual behaviour in relation to searching for client information online, DiLillo and Gale (2011) report that 97.8% of trainees searched for information pertaining to at least one client in the previous year and over 80% of the trainees reported that their clients were aware of the search. While such searches were conducted by most of the participants, 67% of them believed it to be, in general, unacceptable to do so. The authors suggest that the variance between the participants declared online practices and their expressed attitudes may have been due in part to being asked to reflect on the acceptability of such practices.

In contrast, in Asay and Lal’s (2014) study with trainees (/V = 407) investigating their internet behaviours, 25% had searched online for information about their clients and almost 50% had sought online information about their supervisors. Interestingly, 74% of trainees reported that they modified information on their social network sites since commencing training and a large majority indicated apprehension about making ethical decisions concerning social media use. The authors noted that trainees seem aware of their online presence and the implications thereof and recommend that training programmes and supervisors facilitate intentional discussion on these issues with trainees.

Practising psychologists were the focus of a study conducted by Van Allen and Roberts (2011) who sought to identify critical incidents whereby client confidentiality or privacy was breached through the use of technology including social media. The incidents reported included examples of an email recipient inappropriately forwarding an email containing confidential client information to third parties and unauthorised access by hospital staff to a patient’s file. Examples of clients compromising their own confidentiality were also reported and related to clients using an unsecured email address to contact their psychologist and sending a Facebook ‘friend request’. To minimise the risk of ethical violations, Van Allen and Roberts (2011) recommend that agencies and practitioners have a secure client record management practice and note that this is particularly imperative when client information is accessed via mobile devices (e.g. smartphones) that do not have adequate security (e.g. encryption or passwords). Acknowledging that having a social media presence is a personal choice, the authors further recommend that practitioners maintain separate personal and professional profiles and pages on social networks and suggest that they develop a social media policy for their practice.

In a survey of social media practices among trainee and qualified child psychologists (N = 246) regarding their own activity and that of their child and adolescent clients, Tunick ct al. (2011) reported that 65% of participants engaged in social networks with most respondents maintaining privacy settings on their profiles. However, 25% of those surveyed reported being ‘friended’ by clients and although most (87%) refused the request a small percentage (3%) accepted the invitation. On enquiring if respondents had read a client’s social network profile, 32% affirmed that they had done so and declared their main motivations as ‘curiosity’, ‘therapeutic concern’ and ‘request by the client or family member’ (Tunick ct al., 2011: 444). In these instances, in excess of 50% had requested the client’s permission or had subsequently informed the client and approximately one third did so without the client’s permission. 41% read a client profile with the client. Respondents who never reviewed a client’s social network refrained from doing so because of boundary violation concerns. When working with adolescents and children, the authors advocate that guidance is given to this vulnerable population and to their parents or carers on the risks and benefits associated with social media engagement.

In their study on the experiences of mental health professionals (N = of 227) relating to seeking client information online, Kolmcs and Taube (2014) reported that 48% of the respondents had deliberately done so without their client’s permission. The types of information sought included ascertaining if the client was part of the practitioner’s social network, criminal records, client relationships and so forth. Although a minority of the participants expressed distress at having sought this information and some considered it as a boundary issue, most of the participants reported that it had little or no effect on the treatment provided or on their therapeutic relationship. In addition, some participants considered the information as helpful, for example, to confirm client disclosures in therapy. However, as the authors note, in the absence of the client’s perspective in this study, it is not possible to determine the actual impact on client outcomes.

Reflecting on the range of issues highlighted in the above studies, the recommendations provided to therapists by Tunick et al. (2011) arc practical suggestions to minimise potential boundary breaches and maximise protection of client confidentiality, privacy and informed consent in the social media context. In summary, they suggest that practitioners;

  • • Continually reflect on their motivations to self-disclosc.
  • • Maintain privacy settings on their social networking sites.
  • • Conduct an examination of the clinical and ethical risks and benefits when considering accessing client information online without their permission.
  • • Develop a social media use policy and discuss this with clients so they arc fully aware and informed about social media use.
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