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Therapeutic Ethics In The Digital Age

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JA2012-2When the Whole World is Watching

By Ofer Zur

The revolution in communication technology has created a new set of ethical dilemmas, which are invading our sessions, whether we know it or not.

No matter how much time we spend at our computers, or how much we love our adorable iPhones and iPads, for those of us older than, say, 45, the Digital Age is a foreign country. Unlike those "digital natives" who were born into the Internet world, learning how to click their tiny thumbs on devices and play smartphone games by age 1 or 2, we are and always will be "digital immigrants," never entirely at home in this new land. Our analog past clings to us and how we think, just as an old-country accent shades an immigrant's speech.

Of course, not all digital newcomers are created equal. Some are enthusiastic digital immigrants, who thrive in the new country (think of Bill Gates and other 40-plus techno-aristocrats). Others are reluctant digital immigrants, who adapt reasonably well, but never with complete fluency and comfort. Then there are the avoiders: whatever forced compromise they make with digital technology, they'll go to their graves vastly preferring the modern technological equivalents of quill pens.

Digital natives, in general, tend to communicate differently from us immigrants. We still prefer phone calls; they prefer texting or online chatting. Even e-mailing is too slow and antiquated for them. They rarely use voice mail. We still read books and (get this!) hard-copy magazines. They surf through various multimedia sources-Facebook, online magazines, political blogs-reading in short, paragraph-sized bursts, often interspersing this hunting-gathering activity with Facebooking or texting. We value old-fashioned privacy much more than they do, and are scandalized by the personally revealing material they post on Facebook and YouTube. For them, much of their real life is conducted online, and they want to be known by the virtual assemblage of "friends" they accumulate there. In short, their sense of self and the world around them differs sharply from ours.

No matter how adept we immigrants may become at using digital gadgets in our personal lives, we often remain clueless about how much they've changed the way many of our clients think and live and about how to integrate Internet technology into our own clinical practices. Most of us have hardly begun to wrap our immigrant brains around the way the Digital Age has created a new set of ethical questions, which, given the pervasiveness of Internet culture, will inevitably invade our sessions. As individual therapists and as a profession, we desperately need to craft workable ethical guidelines to help us navigate this foreign territory. The basic issues-self-disclosure, confidentiality, boundaries, and dual relationships-are the same as they've always been, but they can take on unexpected shapes when manifested via Internet technologies. The difficulties may be compounded when state and federal regulations-like Health Insurance Portability and Accountability Act (HIPAA) rules and state licensing requirements-conflict or are incompatible with the ways therapists use the new digital technologies to engage in therapy.

Unfortunately, many of us have a hard time accepting the reality of our own immigrant status and ignorance. Rather than admitting that we don't really understand how this new technology has changed the way many of our clients actually think and perceive the world, or that we're ourselves intimidated by it, we assume a posture of professional superiority and declare it all "inappropriate" or "unethical." "Texting is unethical," we proclaim, for example, even though it is, by far, the most effective way of reaching adolescent clients. We reflexively dismiss phone or e-mail therapy because it doesn't adhere to the hallowed tradition of face-to-face contact, even though "telepsychology" has extensive scientific support and can expand our ability to affect people's lives by allowing practitioners to conduct sessions with homebound patients or do crisis intervention between in-person sessions.

Googling Therapists and . . . Clients

Nothing does more to put some traditionalists' knickers in a twist than the thought of revealing themselves on Google or, heaven forbid, Facebook. In the old days of psychoanalytically based therapy, self-disclosure was regarded suspiciously: knowing something about the therapist might interfere with the holy transference! Today, therapists are likelier to believe that a conscientious and judicious sharing of some information about themselves enhances the therapeutic connection, increases compliance with clinical directives between sessions, and is an integral part of effective online marketing. But digital technology takes self-disclosure to new realms, often separating the self from the disclosure entirely. Many of us would be aghast to realize how much personal information about us clients can ferret out of the Web-without our consent or even our knowledge.

Modern consumers expect and demand transparency from just about everybody they hire: plumbers, hairdressers, doctors, real estate agents, gardeners, and therapists. These clients won't just assume that because you look presentable and have a diploma or certificate on your wall that you're the right therapist for them. Many, even most, clients today will Google us before the first session. So, it does no good to assert, as one 70-year-old therapist said to me, "If my clients Google me before they come to see me, I won't see them." Over time, this will be a recipe for seeing no clients at all. The question isn't whether you should have an online presence (you already do), but how to manage it in a way that's honest, ethical, and attractive, and conveys an image of you as a caring, competent professional.

But what about Googling or conducting an online search on clients? Is it ethical, appropriate, clinically sound, generally OK? Again, the old-timers in the analytic world would have been shocked to consider snooping around for information about clients behind their backs-it would have marred the pristine purity of the therapeutic session. But again, for increasing numbers of people, to live is to Google. Many of our clients, particularly young digital natives, do it all the time and would probably find it odd if you didn't. Still, we also have clients-digital immigrants like most of us-who don't plaster their lives all over the Web and would feel violated if they thought their therapist was a digital Peeping Tom. This issue, like just about every other issue related to psychotherapy and digital ethics, is awash in unanswered questions.

When might it be a reasonably good idea to Google clients? You might want to do a search on a potential client before the first session when you sense something not quite right about him or her. For example, you wonder whether this client, who doesn't sound particularly well-spoken or educated on the phone, is bragging or delusional when claiming to be the president of a Fortune 500 company. Or you're a psychiatric nurse in an emergency room attending to an unconscious young patient who, according to her family, had attempted suicide. You consider going online to see if she has a blog or Facebook profile, on which she might have posted a suicide note or left information about what combination of meds and alcohol she's taken. This might save her life.

More prosaically, as a single woman practicing out of a home office, in a clinic, or a professional building after hours, when everybody else has left for the day, you might want to conduct a due diligence search just to make sure your potential client isn't wanted in five states for sexual assault on women.

After you've been seeing a client for a while, you could find yourself regretting that you didn't do more rooting around on the Web for information before you started seeing him or her. Let's say you're treating a man for his long-running difficulties with sexuality and intimacy, but you're making little progress and sense vaguely that he isn't leveling with you. Upon Googling him, you discover that he has an active and violent porn website, which he hasn't mentioned in therapy. Perhaps you discover that your unusually angry and volatile client has a history of filing board complaints against former therapists, and has sued a couple of them. These are just a couple of the many real stories told me by clinicians I've known or consulted with, and I'm sure most therapists have had at least a few such "oops" discoveries about their own clients.

As with all questions about the brave new world of digital ethics, the answer to whether you should or shouldn't Google clients is a firm, unequivocal "it all depends." Do you feel professionally and ethically comfortable about using Google? More important, how does your client feel about your doing a search on him? How would the information about your client gained from your online searches affect the process of therapy and the therapeutic relationship? Is it ever ethical to conduct an online search on a client without her knowledge? Must you inform your client afteryou've Googled him? What if you Google your client-without telling him-and find clinically significant information about which the client has said nothing-like the porn king above? Do you document your searches? Again, it may all sound like a hopeless morass. But like other ethical issues, determining an ethically (and legally) sustainable posture on this question requires, first, that you examine your own attitudes about Googling clients. Do you think you have as much right to Google them as they do you-in which case, getting informed consent isn't necessary? Or do you think an online search is tantamount to collecting information from a third party about the client, in which case, informed consent is mandatory?

Personally, I'm a fan of generalized informed consent. Before therapy begins, every client of mine signs a contract that includes office policies, informed consent, and the following: "Dr. Zur may conduct a Web search on his clients before the beginning of therapy or during therapy. If you have concerns or questions regarding this practice, please discuss it with him." For more information about Googling, see: http://www.zurinstitute.com/google2_clinicalupdate.html.

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