Research roundup: When your private therapeutic relationships become public

Our digital world is constantly expanding, and this has created a wealth of opportunities for psychologists around continuing education, telehealth, marketing and practice management. Unfortunately, new technology also creates challenges related to privacy, security and other ethical concerns.

In this installment of “Research Roundup,” we look at new studies exploring how the private therapeutic relationship can be put at risk by search engines, social media, and online reviews.

In addition to reviewing these research summaries, we encourage psychologists are to explore the literature more completely to determine what may be useful to them in practice.

Kolmes, K., & Taube, D.O. (2019). Yelped: Psychotherapy in the time of online consumer reviews. Practice Innovations, 4(4), 205–213. https://doi.org/10.1037/pri0000093

Increasingly, the internet is where we turn for the latest news and even many of our social interactions. And now, more patients are looking at online reviews of their health-care providers, including psychologists.

Ethically, psychologists cannot respond to online reviews or solicit testimonials from current clients, but that doesn’t stop patients from writing them on such sites as Yelp and Healthgrades. This study looked at survey data from 131 respondents who had either left an online review of their psychotherapist or who had found such a review online to better understand the impact these encounters had on the patients’ views of their psychotherapist and their treatments.

Over half of the participants who found online reviews of their psychotherapist discovered positive reviews, around a third found mixed reviews, and 11% found negative reviews. Most (62%) did not believe the review influenced their feelings about treatment. For those who were affected, some disliked the feelings the reviews elicited, reporting it made them compare their relationship with the psychotherapist to the relationships of the reviewers. Others felt validation about their experiences in treatment, positive or negative.

For participants who left reviews of their psychotherapist, over three-quarters left positive ones, while 22% left negative reviews, and 6% felt their reviews were mixed. Interestingly, 88% of those who left a review of their psychotherapist while still in treatment reported that they had not discussed the review with their psychotherapist. When asked for further details, a small group of participants described leaving reviews for reasons other than wanting to share their satisfaction, for example a participant said they left a positive review because they believed another patient was unfair in their review of a mutual clinician.

Knox, S., Connelly, J., Rochlen, A.B., Clinton, M., Butler, M., & Lineback, S. (2019). How therapists navigate Facebook with clients. Training and Education in Professional Psychology. Advance online publication. https://doi.org/10.1037/tep0000267

Social media networks like Facebook, Twitter, and LinkedIn are widely used in the United States and allow for new methods of communicating (posting, sharing, liking, friending) that may pose unique ethical and practical risks for psychologists and their patients. In this qualitative study, the authors interviewed eight mental health professionals (six of whom were psychologists) to examine how they approach social media with their patients.

The researchers concentrated on Facebook to ensure consistency across participants and asked each clinician to focus on a specific significant Facebook event (i.e. requests to become “Facebook friends”) with a patient they had seen for at least five sessions within the past two years. Most commonly, issues arose with patients who had either sent a friend request to the clinician or to a close family member of the clinician, or with patients who had sent private messages to the clinician through Facebook. Sometimes, during treatment, patients referenced personal information they obtained about the therapist through their Facebook connections (such as on the therapist’s spouse’s profile).

In such situations, study participants typically explained to their patients why they could not be Facebook friends, citing professional responsibilities and the lack of confidentiality. The consequences of the events/discussions were generally positive. Participants felt that they were able to communicate that appropriate boundaries between patients and clinicians provide the most therapeutic environments for their patients.

These discussions also prompted participants to clarify and strengthen their social media policies and practices. There were negative outcomes as well. Some patients were embarrassed or ashamed for seeking Facebook contact with their therapist; others felt hurt by the perceived rejection.

Based on their own experiences, the clinicians offered advice for their colleagues on social media. Generally, this included implementing strict and consistent policies regarding social media contact and disclosing this information upfront. A few participants also recommended that therapists be “careful and professional” on social media, suggesting that they change their profile names if they do not want patients to locate them.

Eichenberg, C., & Herzberg, P.Y. (2016). Do therapists Google their patients? A survey among psychotherapists. Journal of Medical Internet Research, 18(1)

The increasing amount of information available on the internet allows psychologists to find out more about their patients, referred to in the literature as “patient-targeted googling” (PTG). What impact could that have on the therapeutic relationship? In this study, 207 German psychotherapists completed an online questionnaire that assessed their experience of and views on PTG.

“When asked if the psychotherapist had thought about using PTG, most (85%) of the psychotherapists reported not actively considering PTG. But when interviewers rephrased the question, asking if providers had simply looked for information about patients online, 40% responded yes and 39% knew colleagues or supervisors who had.

When asked about their attitudes toward PTG, more than one-third of therapists reported that searching for patient information on the web was never OK. The remaining two-thirds said that certain situations could indicate or allow PTG. For example, with consensual agreement from the patient, instances where there was imminent danger, or if there was reasonable suspicion that the patient was lying. Those against PTG elaborated that they were concerned about damaging the patient’s trust and believed that patients should have the right to decide what information they wanted to share.

A closer look at the participants showed no difference in gender or age on the likelihood to participate in PTG or between types of therapeutic treatment provided or age class of the patients. Only the frequency of internet use was significantly correlated with the probability of PTG. Therapists trained in psychodynamic-oriented therapy or psychoanalytical therapy were more likely to report that that PTG is inappropriate in all situations than cognitive behavioral therapists. Only 2% of participants had received information regarding PTG during their education or training.

Results from these studies suggest that psychologists may wish to consider the impact that the internet has on their practices and their relationships with patients. Psychologists are encouraged to develop electronic and social media policies and introduce them as a part of the informed consent procedure. In developing these and other policies, psychologists may want to consider the impact PTG might have on therapeutic relationships.

Psychologists who appear on business listing sites or other consumer review sites may want to specifically note in their policies that a presence on such a site is not a request or invitation for online reviews or testimonials. Kolmes & Taube recommend that clinicians routinely check their data on consumer review sites so they are aware of information that may be visible to patients and consider seeking clinical, ethical, or risk management consultations when necessary. Further, collecting outcome or treatment satisfaction data from clients may provide psychologists with evidence of treatment efficacy and provide patients with an alternative way to discuss satisfaction or displeasure with services.

Knox et al. suggest that psychologists who maintain a social media presence educate themselves on the types of information that can be obtained even when not directly “connected” to a patient or potential patient and consider how their presence on social media may be perceived.

Throughout the treatment process, clinicians may want to talk about and normalize the discovery of information patients may find on the internet. Such discussions can help patients feel more comfortable bringing the information to the psychologist’s attention—and protect the patient-clinician relationship.