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Therapeutic Ethics In The Digital Age - Page 3

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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 and other websites, including, 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 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 (, 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 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 ( 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!

Ofer Zur, Ph.D., the director of the Zur Institute, is a licensed psychologist and forensic and ethics consultant. His focus is digital ethics, private practice outside managed care, ethics, standard of care, boundaries, dual relationships, and issues related to psychology and the Web. His books include Dual Relationships and Psychotherapy and HIPAA Compliance Kit and Forms. Contact: Tell us what you think about this article by e-mail at, or at Log in and you'll find the comment section on every page of the online Magazine.

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