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.
To Accept or Not to Accept “Friending”
Currently, more than 900 million people around the world-and more than 157 million in the United States-have Facebook pages, and at least some of them may be your clients. Clearly, the issue of when, or whether, to use Facebook touches on just about every clinical and ethical issue of importance to therapists, particularly issues relating to boundaries and dual relationships. Should you even have a Facebook page, and if so, how much of your private life should you show? Who should see what? Should you use Facebook’s privacy settings to distinguish what you show among colleagues, best friends, family members, and old, new, and potential clients? How do you respond to clients who want “to friend” you?
Some outdated traditionalists or clueless digital immigrants disapprove of having a Facebook page at all, even if it’s strictly professional-the Web equivalent of name, rank, and serial number. Frankly, at a time when virtually all successful businesses have online presences, including Facebook pages, it’s reactionary in the extreme-maybe even just plain dumb-for therapists not to have at least a Facebook page, if not a full profile. A page can be strictly professional-your upcoming seminars, books, therapy center, clinical philosophy-while a profile might include your college reunion photos and all those cute pictures of your kids with their pet goldfish. As to what goes on your Facebook page-should you choose to have one-I tend to favor keeping it reasonably chaste in terms of personal details and imagery: no photos of you and your bar buddies getting sloshed, no pictures of you skiing, partying, and snorkeling off the Great Barrier Reef; only circumscribed information, if any, about your family. Nonetheless, many younger digital native therapists are far less reticent than I am, and they have no qualms about showing themselves bikinied and beaching, beer can in hand. After all, therapists are allowed to have personal lives, too, and wearing a bikini (and drinking) are perfectly legal, ethically neutral, activities.
What about allowing clients to friend you? Included in my informed consent form, under “Social Networking Policy,” is a statement my clients sign: “Dr. Zur does not accept friend requests.” There’s little question that allowing clients to friend you on your Facebook page constitutes a social dual relationship. In therapy, there are a host of potentially sticky issues involved when deciding whether to accept a client’s friend request-the stage of therapy and the nature of the therapeutic relationship, the state of the client (high-functioning professional or disturbed borderline; someone who needs clear limits or someone who can benefit from more flexibility), the meaning of the request for the client and for you, issues of confidentiality, and so on.
Allowing clients to friend you isn’t always a bad thing necessarily, though it does require foresight. A colleague and old friend, for example, who’s already a friend on your Facebook page, might want to see you professionally for a few sessions, perhaps to help her process her recent cancer diagnosis. It might actually be clinically harmful to take a rigid position and expel her from your friends list.
Again, the whole issue of whether to friend can be a minefield. It stands to reason that deleting a client-friend from the Facebook page could be devastating, and it wouldn’t be pleasant to confront an angry client wondering why you didn’t permit him to friend you, when you did allow others to. For me, it seems cleaner and simpler, not to mention less anxiety-provoking, just to say no to all clients’ friend requests. You can, however, have “fans” on your Facebook page-I do.
Like other boundary issues-whether to touch a client or accept gifts, for instance-the decision about whether to friend requires clinical discernment, great tact, and perhaps some fail-safe policies in case the decision to allow a client to friend you explodes in your face.
The Ethics of E-mail
A client e-mails me, wanting to change his appointment for the following week. I swiftly respond affirmatively. I shoot off an e-mail to another client asking her if she could change her appointment to a different time. Within minutes, she responds with a one-word answer: yes. Two scheduling changes that, before e-mail, might have required hours, if not days, of phone tag and time wasted in polite chit-chat. Isn’t e-mail great?
Then one morning, I check my e-mail at 9:00 a.m. and see that a client has sent me a message at 2:00 a.m., “Doctor, I can’t take it any longer!!!” What do I do now? Send an e-mail back, try to call her, call her listed emergency number (not a good idea-it’s her toxic mother), call 911?
Another time, a client begins an e-mail with, “I know we ran out of time last session, but there was something else I wanted to tell you,” and then writes several convoluted pages, which I briefly skim through because I don’t have a half-hour to read it carefully, much less respond. Later, a client e-mails me with a long account of a fight she had with her best friend-the topic of conversation during many of our sessions. I respond briefly that I’m sorry about the fight and that we’ll talk about it next session, whereupon she writes a furious e-mail, expressing her anger at my “dismissive” and “callous” response. Clients often ask their therapists “quick” questions via “brief” e-mails, like, “My mother is coming over tonight. Should I bring up with her what we discussed in our last session about my brother molesting me?” or “I met this girl, she seems perfect, and we have a date later tonight. But I’m freaking out-do you have any quick advice?”
E-mail was supposed to make our lives easier, but now we may spend much of our out-of-session time on the lookout for and responding to messages from depressed, suicidal, homicidal, angry, panicky clients who want a response that minute. And if we don’t, we may have to deal with the consequences later. What do we do if the client who “can’t take it any longer” does commit suicide? How do we deal with the clients who become deeply disappointed or enraged with us, accusing us of “brushing them off,” when we don’t instantly respond to their fervid e-mails? You could argue that these people have a point. When the Internet and digital mobile devices have created a culture of speed in which instantaneous communication is the norm, why wouldn’t they expect you to get back to them immediately? Don’t you get a little impatient when someone doesn’t respond fairly soon to your e-mails?
Again, e-mail raises the same questions of professional obligations and ethics, not to mention legal due diligence, as other aspects of therapy. The difference is that, with e-mail, we can theoretically be “available” to our clients 24/7. Are the e-mails we send or receive considered part of psychotherapy? Yes, they are, just as phone contacts with clients are considered part of the clinical process and, therefore, part of the clinical record. Do we have the same obligation to check, read, and answer our e-mails as we do to show up on time for sessions? It all depends on the policies we set in place. Many therapists put in their initial informed consent that they usually respond to e-mails within 24 or 48 hours during weekdays.
The fact that you give your e-mail address to clients doesn’t obligate you to check daily or even weekly-as long as you give your client written and verbal communication about how frequently you check e-mails, whether you respond to them, and how soon. It’s recommended that each and every e-mail go out with an electronic signature at the bottom-an automatic enclosure with a statement of office e-mail policy. Mine has the standard boilerplate about confidentiality, the potential for unauthorized access (noting that my e-mails aren’t encrypted), and a request to the client to notify me if he or she wants to avoid or limit e-mails, with an instruction not to use e-mail for emergencies. I indicate in the signature that, unless otherwise notified, I’ll communicate with the client by e-mail “when necessary or appropriate.” I point out that I don’t check my e-mails daily, and sometimes not for weeks at a time.
There’s often something of a flurry around the issue of encryption and whether therapists should use it for reasons of confidentiality. As with all things Internet related, this is a murky subject. Most therapists use standard e-mail services, like Yahoo!, Gmail, or, for Mac users, Mail. None of these use encryption and all of them allow e-mails to “sit” in the computer’s inbox, supposedly perusable by every passing Tom, Jane, or Harry. Some therapists, it’s true, use a more secured and encrypted e-mail service, like Hushmail (www.hushmail.com), which requires clients to create new e-mail accounts and use passwords. Since what draws people to e-mail is its ease, simplicity, and convenience, this extra security turns off many clients. There are even fancier and far more secure telemental health software platforms, which offer not only e-mail, but also confidential video conferencing, data-storage capacity, and other bells and whistles.
Since e-mail is considered a part of therapy, the question becomes how much a part, and what the parameters are-whether you use it as an administrative convenience for scheduling appointments, commit yourself to read and respond quickly to lengthy e-mails, or engage in various levels of communication in between these poles. These questions should be determined with your clients in advance, probably in office policy and informed consent documents, as well as in face-to-face conversation. If you’re willing to engage in dialogue and treatment via e-mail in conjunction with in-person therapy, it’s important to discuss this ahead of time, as well as how you intend to charge for these services. Otherwise, you need to make clear how you’ll use e-mail and what the limits will be. Generally, unencrypted e-mails should be limited to administrative concerns, such as scheduling and billing. Since this kind of unencrypted usage is so common among therapists, it may constitute “the usual and customary professional standard of care,” which suggests some margin of legal and ethical safety.
But humans always push boundaries. Even though you may explain, multiple times, the dicey nature of e-mail privacy and confidentiality and ask your clients to limit their messages to administrative matters, some-like those mentioned above-will choose to write you lengthy, revealing e-mails anyway. If they’re digital natives or even comfortable immigrants, they don’t worry much about privacy to begin with. The fact is that the strictures of security experts-never use unencrypted e-mails for anything important or confidential-are pretty unrealistic, particularly in the world of therapist-client communications. Not to sound like a broken record (a simile most young digital natives won’t recognize!), but unless you opt to prohibit all e-mail communications with clients, you’ll have to tolerate a little fumbling around in the gray area of this issue. Just remember that even after you’ve had “the discussion” about e-mail and tried to clarify your boundaries during the first few sessions, you should be open to continuing an ongoing dialogue on the subject as clinically and ethically necessary throughout therapy.
Texting and Cell Phones
Recently, I consulted with a therapist working with volatile adolescents, who described to me how accessible and responsive these youngsters are to their texts. He reiterated what any parents of teenagers in the digital world know: the best, and sometimes only, way to reach many young people is via texts. They rarely respond to e-mails or check their voice mail, but they always respond to texts-mostly from friends, but, by default, from parents and therapists, too.
Digital-immigrant therapists (particularly resentful immigrants) are the ones most likely to claim that “texts are unethical,” rather than admit that their unease derives mainly from lack of experience with this texting world. If prolonged, intimate, person-to-person communication is the heart and soul of therapy, what’s with all this tapping and typed messaging? But, increasingly, as landlines seem to be joining the telegraph in the dimly recalled past, more people are relying exclusively on cell phones and using texting for quick, simple communications. In fact, about the only way to reach your suicidal, young client in a hurry may be by texting.
As with e-mails, you need to record or archive phone messages and texts if they are germane to treatment. A simple way to do this, of course, is to enter a handwritten or typed note in the records that describes the content of these communications. FYI, you can simply take a “screen shot” of the text messages. However you do it, it’s important to find a method of keeping accurate records of messages with clinically significant content that makes sense for you and your practice. You also need to consider the issue of informed consent, notifying clients about the inherent risk of privacy breaches related to these online communications, as well as the digital records of them.
Using Digital Devices in Session
Any therapist might think that having a client texting, looking at videos, or taking cell-phone calls during therapy is massively disruptive, therapeutically inappropriate, and egregiously rude. But for digital natives, using their stuff anytime, anywhere is as natural as breathing. Certainly, if your teenage clients get a text message, they won’t think twice about texting back, wherever they are. They can respond without even looking while in class, at the dinner table, or . . . during therapy. Are you going to replay the role of their parents and teachers and throw a tantrum about their inability to pay attention to you?
As with all things, discernment and discretion are key, but you might be surprised by the clinical possibilities these apparent interruptions can provide. Recently, a client received a video he’d helped edit that he wanted to look at on his iPad while we were in session. What’s more, he wanted me to look at it with him and tell him what I thought. I was happy that this rather shy, withdrawn young man, who finds it hard to communicate verbally, had invited me into the sacred space of his creativity. Watching his video not only gave me insights into him and his view of the world, but opened up a valuable channel of conversation and connection, which carried over into our clinical work. In another session, a woman invited me to sit by her and look at her iPad to see her new website, as well as some photos of friends whom she’d discussed in therapy, which she’d posted on her Facebook page. This information was extremely helpful clinically, as it gave me a deeper sense of her values and social engagements.
Finally, I’ve often gotten entirely new insights into people and their problems by listening to them talk on their iPhones. Some time ago, a male client who presented himself as cordial, composed, and emotionally regulated answered his cell phone during a session and completely lost it with his girlfriend within a minute. Shouting, swearing, insulting, and blaming her, he gave a telling look at a part of himself that I hadn’t seen-which opened up an opportunity to discuss issues that might otherwise have taken months to surface.
The Dark Side of the Web
As therapists, we’re all used to situations in which clients get angry with us, sometimes with extreme intensity, but in today’s world, clients can register their negative feelings about you on the Web with potentially disastrous consequences. Let’s imagine your borderline client, who loved you last week, hates you this week, and decides one afternoon that you’ve ruined her life. She goes online, starts a new website with your name as the URL, and then posts her unflattering views about your therapy, your office, your personality, and the way you do your hair. Later, she branches out, putting her opinions up on www.Yelp.com and other websites, including http://www.complaintsboard.com/bysubcategory/doctors/, a kind of all-purpose, all-category, consumer-run complaint site that takes reports about every bad experience with every product or malefactor in every field. She tweets and blogs about you as well, and within hours, there are more than 50 negative postings online, which get picked up and spread to other blogs and chat rooms. Admittedly, this probably doesn’t happen often, but we do hear about such cases from time to time, and many of us agree that these digital weapons offer a tempting means of retaliation for injuries, real or assumed.
What do you do if you find information about yourself online that’s false, mistaken, misrepresentative, or inflammatory that a client has posted? Whatever you do, don’t call the client, which would most likely only encourage more attacks. You might begin by figuring out the source of the information. Did it come or evolve from something you might have posted online in a private or public Internet setting-a blog, a chat room, an electronic mailing list, your own website, an article or book you published, a complaint site? After that, you can take a number of steps, including finding and contacting the owner or manager of the website and politely asking him or her to remove or amend the information. You can find out who owns the website by going to www.networksolutions.com/whois/index.jsp. If the website owner/manager refuses to change the false or negative posting, you may want to ask, respectfully, whether you could be allowed to rebut the information. You’re allowed to defend yourself, but you have to attend to issues of confidentiality and related legal issues. If the flamer attacks you on a site designed for customer feedback, such as Yelp, you can, of course, respond with your own postings, which you must do carefully because of confidentiality restrictions and the likelihood that Yelp won’t print them.
Consult prior to responding. Sometimes responding creates more fire. You may want to let a barking dog lie. While it’s not ethical to solicit clients’ favorable testimonials in your defense, you may ask colleagues, supervisors, graduate school professors, and so on to put in a good word for you. Many clinicians that I’ve consulted with reported to me that Yelp seems to be “happy” to post negative reviews and much more reluctant to post positive reviews. This is confirmed by comments on the Internet.
To help protect yourself from at least some of the vast number of “online information brokers”-the websites that gather and then sell or give away personal information they’ve gathered on individuals-go to the Privacy Rights Clearinghouse (http://www.privacyrights.org/), a consumer-protection organization that lists many of these sites and provides tips on how, when possible, to opt out of providing information to some of them, remove your information from various listings, and submit complaints to the Federal Trade Commission. You can contact reputation.com to see whether and how this reputation-defending organization may be able to help you, although I’ve received mixed reviews on the impact of their services. Just remember that if you respond to any negative postings prematurely or ineffectively, you may cause more damage, so it’s worth consulting (and consulting and consulting!) with colleagues or online services.
Now that I’ve got you hyperventilating, you should know that there are basic, common-sense steps that can provide protection from the more common perils of too much online disclosure. The single most important rule is to be aware of your own Web presence. You can’t correct or attend to the misleading or out-of-date information you don’t see. Google yourself regularly, using different combinations of your name (“Ofer Zur Ph.D.,” “O. Zur psychologist,” etc.). Even better, sign up for “Google Alerts.” This service allows you to monitor the Web for any new mention of a subject that interests you-developing news stories, particular sports teams, activities (hiking, biking), celebrities, businesses, medical or scientific issues, and, as it turns out, your own name! This is a great way to discover who sees what about you on a regular basis. Besides getting Google Alerts (http://www.google.com/alerts) every time my name shows up, I get about 25 other Google Alerts on webpages mentioning issues important to me, including gifts and therapy, dual relationships in therapy, bartering in therapy, self-disclosure in counseling, and so on. Just after you sign up, expect a deluge; after that, you’ll mostly get new postings on the topic.
Getting to Feel at Home in Digital Land
In a sense, we digital immigrants have to find a way to learn about and respect this unfamiliar territory, just as if we were going to do therapy with the people from the steppes of Outer Mongolia or the jungles of Brazil, even if we don’t necessarily want to “go native” ourselves. Since the beginning of the Age of Therapy more than a century ago, the methods, mores, and even ethics of the profession have changed, along with all the social and cultural changes that have taken place around the field. To do our job well requires that we demonstrate to our clients that we inhabit the 21st century.
Of course, the ancient truths concerning the relationship between healer and client must still guide our work. Therapy remains a personal, private connection between a therapist and a client, couple, or family, in which security, emotional safety, and confidentiality are vital. With care, thoughtfulness, and a certain amount of caution, we immigrants may one day even find ourselves comfortably at home in Digital Land. Who knows? Maybe we’ll even take out citizenship papers!
Illustration © Jane Marinsky
Ofer Zur, PhD, director of the Zur Institute, is a licensed psychologist from Sonoma, California. He‘s written dozens of articles and four books, including Dual Relationships and Psychotherapy and Boundaries in Psychotherapy.