When Marshall McLuhan stated that “the medium is the message” (1964), he probably didn’t realise how prophetic his words would become a half-century later. Yet the exponential growth in online technology shapes ever more firmly how individuals learn, interact, and entertain themselves. Mental health professionals have offered treatment via communication technologies since the 1990s (Smith & Reynolds, 2002), and cyber technology has permeated with increasing depth the ways in which both adults and youth seek support for an ever-wider range of services (Mishna, Bogo, Root, Sawyer, & Khoury-Kassabri, 2012).

How can you, as a therapist, ethically navigate through the alien landscape of counselling’s Digital Age? In this article, we identify both possibilities and risks for the therapeutic relationship made possible by recent online technologies.

Opportunities emerging via social media

The social media scene – so familiar to the “digital natives” (young people who have never known a world without the internet or the above potentials for connecting) – also beckons alluringly to many “digital immigrants” (Zur & Zur, 2010): internet users old enough to compare the contemporary world of digital technologies with the ancient world “B.C.” (before connectivity). To the extent that they understand and know how to participate in social media, even the “immigrants” can grasp how advancements in communication technologies, and especially social media, afford mental health practitioners the opportunity to do research and provide services in more unique and far-reaching ways than before. The lifting of heretofore restrictive conditions – by virtue of geographic location, time zone, mobility constraints, and the social stigma of simply showing up at the counsellor’s office – are overcome by new and improved possibilities for anonymity, easy access, and greater flexibility. Let us examine some of those enhanced opportunities.

Psychological research is simpler; healthcare surveys are facilitated

The use of confidentiality protocols and anonymity features associated with online studies mean that the stigma often linked to completing healthcare surveys and mental health questionnaires is reduced or eliminated (Griffiths, Lindenmeyer, Powell, Lowe, & Thorogood, 2006).

There is improved capacity to screen for depressive symptomatology

Some clinicians believe that social networking sites hold promise for enhanced capacity to screen for depression because it is on these sites that people disclose depressed feelings and let suicidal ideation or actual suicide attempts be known (Moreno et al, 2011).

The internet is a source of health information

Websites containing health information and resources have proliferated, as has the tendency to take up services after searching for them online. This possibility is linked to a related potential: that of health professionals setting up a professional profile page as an extension of their practice (Vance, Howe, & Dellavalle, 2009).

Health professionals can introduce and market themselves online

An online page – which can be strictly professional – can let actual and potential clients know of services offered; products sold (such as books or other items); and seminars, courses, and webinars offered. Certainly, professionals can clearly display their philosophy and the orientation of their training, in order to attract more suitable clients. In the comfort of their own home or other chosen location, clients and those enquiring can search and contact a professional for help in resolving relational and other life issues. They can do this without the barriers imposed by geography, time constraints, guilt, shame, or stigma (Giota & Kleftaras, 2014).

There is greater flexibility and accessibility

Those desiring services but who have mobility problems or live in remote areas have as much possibility of getting counselling as those living two doors from the professional’s office. When support is needed between sessions for crisis intervention, it can be there for clients (Kolmes, 2010a).

Social media sites can be harnessed to create intervention initiatives

Clients who utilise social media sites in their daily lives can benefit from tools available on a platform with which they are already familiar. That this strategy is successful is attested to by the sharp rise in both texting help lines (communicating through text messages from mobile phones) and via online chatting on the sites. This is as opposed to calling the traditional 800 hotline numbers. Clearly, digital technologies are improving the therapeutic experience as well as the access to therapeutic interventions (Giota & Kleftaras, 2014).

Follow-ups, protocols, and reminders can flow

For many clients, successful treatment is a consequence of the medication taken, the regular journal entry made, or the commitment to daily exercise kept. Online technologies greatly facilitate the sending-out of daily, weekly, or monthly reminders to carry on with agreed programs and initiatives. Text messages and audio and video clips can explain the protocols to be followed, remind the client of what is to be done, and re-inspire those struggling to keep a commitment for which energy and motivation may be flagging (Postel, de Haan, & De Jong, 2008).

Online programs can be created to support clients in alleviating many conditions between sessions

Whether the support is delivered via mobile phone or online, whether it is mostly to supplant face-to-face therapy or as an adjunct to other modalities, help for conditions from anxiety and depression to avoidant personality disorder and borderline personality disorder can be delivered via social media sites and other online technologies (Giota & Kleftaras, 2014).

Social networking sites can provide valuable insights to mental health professionals to help clients understand themselves

Before online technologies were available, counsellors obtained information from clients face-to-face. Contemporary social networking sites such as Facebook tend to foster high levels of self-disclosure, giving professionals viewing them important information to facilitate understanding of what the client is experiencing. During sessions, candid discussions of the client’s Facebook behaviour (or other online interactions) can provide further insights into the client’s thoughts and feelings, and also offer feedback as to how the therapy is proceeding (Krasnova, Spiekermann, Koroleva, & Hildebrand, 2010).

Navigating the risks: Ethical principles relevant to use of social media

Considering the new possibilities for enhancing counselling with social media is analogous to viewing a terrain with rose-coloured glasses on; things look lovely! Yet if we are serious about the primary injunction to “do no harm” in our interactions with clients, we also have the complementary task of removing the glasses and scrutinising the territory – the digital landscape – with unflinching honesty regarding the risks. These arise in the context of the ethical principles which it is harder, or even impossible, to uphold in the same way as before online technologies invaded our counselling spaces. Although many of the risks manifest in unique ways, they stem from the same old issues that professional helpers have faced from time immemorial: the questions of boundaries – with the corollary issues of confidentiality and dual or multiple relationships – and the related issue of disclosure: how much client and practitioner should know about each other – and how they get the information.

The increasing challenge to maintain strict boundaries between client and therapist becomes obvious when we reflect that, not so long ago having an unlisted personal telephone number was considered an effective means of safeguarding solid boundaries between one’s personal and professional lives. In the contemporary online world, it takes only moderate computer savvy and a few clicks of the mouse for clients to obtain professionals’ personal information online, make “Friend” requests, and gain mobile phone numbers in order to text or telephone the practitioner, which an online survey revealed that eight out of ten respondents had attempted to do in their search for health information and/or a particular health care professional (Fox, 2011). Let us remind ourselves of why this potential is consequential.

The primacy of boundaries in the helping relationship

No competent mental health professional would disagree that the interests of the client must be protected above those of the service provider. Solid boundaries, membranes of safety, encircle the client-counsellor relationship, with confidentiality, single-role relationships, and informed consent lying inside the circle and the possibility of client harm lurking outside. A boundary is a line which, by definition, includes some things and excludes others; in this case, it includes counselling and excludes what counselling should not be. Keeping such lines clean and clear is essential for counselling professionals for two reasons.

First, we are mandated legally, morally, and ethically, to do no harm to our clients; clear boundaries make it more likely that we can fulfil this responsibility. If as counselling professionals we fail in this duty, not only do we damage the therapeutic relationship; we also do psychological or even physical harm to our clients. Second, violated boundaries can also hurt the reputation of counselling and psychology as disciplines. Society expects us to act toward clients in ways that help, not harm; when this does not happen and client rights are not adequately protected, the public can lose faith in counselling as a profession.

Yet despite counselling professionals’ presumed awareness of how important boundaries are, a meta-analysis of studies from nine countries found that boundary problems were a common occurrence. In six out of the nine countries studied (i.e., in the U.S.A., Canada, Sweden, Finland, New Zealand, and South Africa) the most common problem was confidentiality, with blurred, dual, or even conflicting relationships being the second most common (Pettifor & Sawchuk, 2006).

Social media and confidentiality issues

In the same way that the imperative for clear boundaries is “programmed” into a helping professional’s mindset from the outset of his or her career, so, too, is the absolute importance of preserving client confidentiality. Because counsellors and other helping professionals hear a vast amount of intimate information from their clients, there are complex legal and ethical obligations to keep that information private. It is a fundamental ethical responsibility to take every reasonable precaution to respect and safeguard a client’s disclosed details. Moreover, counsellors, social workers, psychologists, psychotherapists, and others have an obligation to protect this information from inappropriate revelation to any person outside the therapeutic relationship (CCPA, 2008), regardless of which medium the information is stored in.

With only face-to-face contact and paper-based record-keeping, this vital mission was obviously much simpler. Online conduct has recently put confidentiality into the spotlight, as the perceived sense of anonymity when using social networks tends to blur the boundaries between acceptable and risky personal and professional behaviour. Social networking sites, in fact, rarely are able to fulfil criteria for confidentiality in counselling associations’ codes of ethics, such as that information can be disclosed only if the client gives full consent, if the counsellor is served a warrant or subpoena demanding information, if there is concern for public health and safety, or if a client’s file contains information necessary for contacting an injured, ill, or deceased client’s next of kin, (Turner, Uhlemann, & Stolz, 2007). The Zur Institute (2014) details the facts about couns ellor communication via “SNS” (social networking sites) and the practical mechanisms whereby social media-engendered communications cause confidentiality breaches.

Passive versus interactive

First, let us note – as the Zur Institute does – that not all social networking sites or situations are entirely problematic. Issues of confidentiality are not likely to be relevant when helping professionals use a passive website, or what is sometimes referred to as a “business card” type website. These describe a practitioner’s practice and expertise. They don’t include a blog with comments enabled or any other sort of reader participation, functioning more like a bulletin board: a one-way communication. Because they do not allow for viewers’ feedback, comments, or responses, they do not pose concerns with confidentiality.

Sites such as Facebook, Twitter, and LinkedIn are interactive; their very purpose is social networking. Active, interactive sites like this present a much greater concern for confidentiality and privacy of client-practitioner communication. The most obvious potential for violation lies in the acceptance (or solicitation) of a “Friend” request on Facebook, where the issue of possible exposure of the client’s identity to others must be addressed. Moreover, exactly what information will be exchanged should be addressed, as others may be privy to a client’s confidential information (Zur Institute, 2014).

Increasing numbers of businesses, including some therapists, clinics, and mental health departments, choose to establish a Facebook Page, rather than a profile. People setting up a Page and a profile typically put only professional information on the Page and employ privacy settings for the profile, which is more private. So far, so good. Generally these are used by/for businesses, celebrities, and public figures. Because they are mostly one-way communication, allowing only the possibility that someone may “Like” the page, they seem safe enough as concerns confidentiality.

They still present dilemmas, however. As Kolmes (2010b) points out, when people have a Page, they still have to decide how they feel about who “Likes” their Page/practice. If you are the professional with the Page, do you want family members who (in an effort to be supportive) have “Liked” you – and their Likes are available for all to see? How do you feel about current or former clients endorsing your Page? Obviously allowing clients to be connected to one’s Page brings up confidentiality issues again. Even on a professionally-oriented Page, supportive clients can Like the Page, thereby joining it and being able to post on the Wall. With this potential, current or former clients can post therapy or other notes, which might not only be awkward for the therapist and others Liking the Page, but it also might be troublesome for confidentiality (especially in the United States, where such actions might mean problems for compliance with the HIPAA (Health Insurance Portability and Accountability Act) (Zur, 2014).

One, not immediately obvious, reason for the confidentiality problems is that not only are counsellors’ communications with clients on social networking sites regarding scheduling, clinical, or other matters confidential, but also they are considered part of clients’ clinical records. As such, they need to be documented in some form in the clients’ files. Some experts do not agree that therapist-client communications through sites such as Twitter and Facebook are able to be confidential. Younggren (2010) argues that these sorts of communications are “completely discoverable” and in no way protected by privilege.

Taking Facebook as an example, we can see several means by which confidentiality can be compromised. For start, privacy settings are confusing – sometimes to digital natives and certainly to digital immigrants, as many mental health professionals are – and they change regularly, so keeping up with the latest rules for the settings is not easy. People may not understand who can see what information on their profiles. Moreover, users must contend with the malign intentions of hackers and others who illegally move past privacy settings to access information without authorisation. If all that were not daunting enough to the professional social network user, there is a whole new potential confidentiality problem to deal with: the burgeoning number of court cases in which magistrates have decided that, under some circumstances, Facebook information must be disclosed (Zur, 2014 ).

We can question whether the sites themselves have some responsibility to help preserve privacy. The short answer is “yes, of course they do”. A browse reveals that sites such as Facebook claim that “We work hard to protect your account using teams of engineers, automated systems, and advanced technology such as encryption and machine learning.” Further on, Facebook asserts, “We have top rate measures in place to help protect you and your data when you use Facebook”. This is followed by discussion of Facebook’s “secure browsing”, meaning that activity is encrypted and there are tools to help detect and remove viruses if one has clicked on a “spammy post”.

Further exploration, however, reveals that the main responsibility for maintaining top-notch security while on Facebook rests with users, who must be savvy enough to operate Facebook’s “easy-to-use security tools that add an extra layer of security to your account” (Facebook, 2015). A private blog showing users how to manage Facebook accounts agrees:

“Social networks like Facebook are open to phishing, malware and other unwanted problems. While there is no perfect solution, you can change your Facebook security settings to help increase your privacy and safety.” (Howe, 2015)

Source: www.mentalhealthacademy.com.au

References

• CCPA (Canadian Counselling and Psychotherapy Association). (2008). Standards of practice for counsellors. Ottawa, Ontario. Canadian Counselling and Psychotherapy Association.
• Fox, S. (2011). Health topics. Pew internet and American life project – California Health Care Foundation. Retrieved from: hyperlink.
• Giota, K.G. & Kleftaras, G. (2014). Social media and counseling: Opportunities, risks and ethical considerations. International Journal of Social, Management, Economics and Business Engineering, Vol 8, No 8, 2014, pp 2248-2250.
• Griffiths, F.E., Lindenmeyer, A., Powell, J., Lowe, P., & Thorogood, M. (2006). Why are health care interventions delivered over the Internet? A review of the published literature. Journal of Medical Internet Research, Vol. 8, no. 2, 2006. Available from: hyperlink.
• Kolmes, K. (2010a). Ethical framework for the use of social media by mental health professionals. Retrieved from hyperlink.
• Krasnova, H., Spiekermann, S., Koroleva, K., & Hildebrand, T. (2010). Online social networks: why we disclose. Journal of Information Technology, Vol. 25, 2010, pp. 109-125.
• Mishna, F., Bogo, M., Root, J., Sawyer, J.L., & Khoury-Kassabri, M. (2012). “It just crept in”: The digital age and implications for social work practice. Clinical Social Work Journal, Vol 40: pp 277-286.
• Moreno, A.M. et al. (2011). Feeling bad on Facebook: Depression disclosures by college students on a social networking site. Depression and Anxiety, Vol. 28, 2011, pp. 447-455.
• Pettifor, J.L., & Sawchuk, T.R. (2006). Psychologists’ perceptions of ethically troubling incidents across international borders. International Journal of Psychology, Vol 41, No 3, 216-225. Doi: 10.1080/00207590500343505.
• Postel, M.G., de Haan, H. A., & De Jong, C. A. J. (2008). E-therapy for mental health problems: a systematic review. Journal of Telemedicine and E-Health, Vol. 14, no. 7, 2008, pp. 707-14. doi: 10.1089/tmj.2007.0111
• Smith, S.D., & Reynolds, C. (2002). Cyber-psychotherapy. Annals of the American Psychotherapy Association, 5, 20-22.
• Turner, D., Uhlemann, M.R., & Stolz, J. (2007). Freedom of information and protection of privacy. In D. Turner & M.R. Uhlemann (Eds.), A legal handbook for the helping professional (pp 413-438). Victoria, B.C.: Sedgewick Society for Consumer and Public Education.
• Vance, K., Howe, W., & Dellavalle, R.P. (2009). Social internet sites as a source of public health information. Clinics in Dermatology Journal, Vol. 27, no. 2, 2009, pp. 133-6. doi: 0.1016/j.det.2008.11.010.
• Younggren, J.N. (2010). To tweet or not to tweet, that is the question. The Clinical Psychologist, Vol 63, no 2, pp 18-19.
• Zur, O. & Zur, A. (2010). On Digital Immigrants & Digital Natives: How the digital divide creates conflict between parents and children, teachers and students, and the older and younger generations. Zur Institute. Online publication, retrieved from hyperlink.
• Zur Institute. (2014). To accept or not to accept? How to respond when clients send “Friend Request” to their psychotherapists or counselors on social networking sites. Retrieved from: hyperlink.