A lot of discussion between therapists about online privacy deals with a unilateral direction of clients seeking out information about the therapists or friend requests or follows on social media. Plenty of space is devoted to proper social media policies to have upfront rules about how a therapist will respond to social media and web requests from clients. Less common, but still present is the way that social media companies use metadata and location services to connect clients to their therapists and each other. But there is also a flip side to this relationship. What about therapists who Google their clients?

“Patient Targeted Googling” (PTG) is when therapists seek information about their clients online. The availability of both personal and public information about clients has grown rapidly over the past few decades, giving therapists an opportunity to learn more information about clients than ever before. These relational boundary crossings can be intentional or unintentional and can be consensual or non-consensual, all of which impacts the way that therapy is practiced. Depending on the timing of these boundary crossings, the impact can affect anything from therapist countertransference to verifying client claims against delusional and psychotic ideation to affecting the ways that therapists set fees.

Theoretical orientation about the acceptability of PTG comes into play when it comes to discussing the acceptability of the practice. Eichenberg & Herzberg (2016) found that therapists trained from a psychoanalytic basis are less likely to engage in PTG than therapists that utilize a cognitive behavioral perspective. They cite the difference in perspectives surrounding the therapeutic relationship, abstinence, and alliance. Therapists from this perspective argue that the client should retain the right to decide what information that they are willing to share and a therapist engaging in PTG damages the bond with the patient. Further, psychoanalytic therapists argue that there is limited potential benefit to engaging in PTG.

Beyond the clinical arguments, there is scant but emerging research on how often therapists are engaging in PTG. Eichenberg & Herzberg (2016) found that 39.6% of German therapists studied had already searched online about their clients and 2/3rds of those who did thought that it would be beneficial to treatment. Other studies place the following instances of PTG: psychiatry residents at 18% (Ginory, Sabatier, & Eth, 2012), therapists and therapists in training at 27% (Lehavot, Barnett, & Powers, 2010), and U.S. and Canadian doctoral students at 89% (DiLillo & Gale, 2011)! DiLillo and Gale went on to say that 67% of those same students said that the practice was universally unacceptable—which leads at least in part to some of the hidden rules around PTG.

Generational aspects may also be at play in this discussion. Ferro (2016) reported that the mean age of psychoanalytic societies is between 70-80 years old, the overall age of the behavioral health workforce is trending downward into the 40’s (APA 2018; data searched on datausa.io using the search terms “psychologist”, “counselor”, “marriage therapist”, and “social worker” retrieved 8/4/2020). Digital natives often serve as the educators, supervisors, and professional gatekeepers have a much different experience and viewpoint on private information than the digital natives who are quickly becoming the majority of the workforce. Digital natives, those born roughly around 1980 and after, are much more likely to see a person’s digital footprint as an extension of self and the accessibility of publicly available information as a natural progression of learning about others. There is therefore an education gap in how digital client information is perceived between the educators and the students, if there is even education discussing digital relationships at all. Those programs that do discuss the issue tend to limit the discussions to “don’t do it”, which leads to the peculiar findings of the DiLillo and Gale (2011) findings mentioned earlier. This leads to several questions: “If we aren’t supposed to, why are so many therapists doing it?”, “Are these acts unethical?” and “Are there situations where therapists should be doing PTG?”.

Why are so many therapists doing it?

Eichenberg and Herzberg’s (2016) survey revealed several answers that range from clinicians desiring to better their understanding of the client to information that is wholly based on clinician personal interests:

  1. Better understanding because of more information and a change of perspective “Better understanding of the patient’s social environment.”
  2. Therapy-relevant information is on the Internet “To be authentic to patients who attach importance to their Web presence.”
  3. Online information is public “Anyone who provides online information needs to expect that it will be read.”
  4. On the request of the patient “After the patient’s explicit request”
  5. “If it is an interesting patient and you want to get to know more about him”
  6. Controlling patients’ statements. “A kind of reality check. Is the patient really as famous as he says?”
  7. Suspicion of lying and concealment. “(Client was) suppressing facts such as criminal proceedings”

Are these acts unethical?

Of the four major national therapist associations – American Psychological Association (APA), American Association of Marriage and Family Therapists (AAMFT), American Counseling Association (ACA), National Association of Clinical Social Workers (NASW) – the ACA is the only code that specifically addresses online client privacy. However, the ACA code is specific to social media:

H.6.c. Client Virtual Presence Counselors respect the privacy of their clients’ presence on social media unless given consent to view such information.   

The absence of ethical codes outlawing PTG is not a passive permission for therapists to search for client information online, but it is also not a prohibition, either. Looking to a sister organization, in the Opinions of the American Psychiatric Association Ethics Committee (2020), this is addressed specifically by:

A.20 Question: Is it ethical to perform an internet search on your patient?

Answer: Performing targeted internet searches on a patient is not, in and of itself, unethical. First and foremost, such searching of a patient should only be done in the interests of promoting patient care and well-being and never to satisfy the curiosity or other needs of the psychiatrist. Also important to consider is how such information will influence treatment, and how the clinician will ultimately use this information. The psychiatrist should ask him or herself these questions before resorting to targeted internet searches. Transparency in treatment relationships is an ethical virtue. Therefore, psychiatrists should make clear to the patient when information is obtained about them from the internet, and the specific source of that information. This also gives the patient an opportunity to potentially refute information obtained in this fashion. (Section 1) (2017)

Are there situations where therapists should be doing PTG?

While most situations seemingly wouldn’t allow for a therapist to engage in PTG without client permission, there are some situations that might require it. These situations would often fall under emergency contact scenarios, such as when a domestic violence situation has arisen with a controlling partner confiscating access to a victim’s normal means of communication, when a client is presenting for high risk of suicidal or homicidal situation, or verifying client claims when considering if a client is presenting with psychosis or delusional beliefs. These types of considerations make it difficult to create blanket rules for all scenarios, but situations like these are clearly for client beneficence rather than clinician curiosity.

Baker, George, & Kauffman, Jr. (2015) gave ten recommendations for physicians that may be worthwhile for therapists to adopt when considering PTG:

1) duty to re-contact/warn patient of possible harm

2) evidence of doctor shopping

3) evasive responses to logical clinical questions

4) claims in a patient’s personal or family history that seem improbable

5) discrepancies between a patient’s verbal history and clinical documentation

6) levels of urgency/aggressiveness incommensurate with clinical assessment

7) receipt of discrediting information from other reliable health professionals that calls the patient’s story into question

8) dissonant or incongruent statements by the patient, or between a patient and their family members

9) suspicions regarding physical and/or substance abuse

10) concerns regarding suicide risk.

 

While doctor shopping concerns may not seem like a prevalent concern for many mental health professionals, it may be a very relevant concern with clients who are attempting to acquire controlled prescriptions for abuse or in an attempt to overdose.

The call to action

The overall call to action is for better training and discussion around PTG in both therapist training and continuing education so that client care is best coordinated. We cannot pretend that therapists aren’t engaging in PTG and thus need better guidelines to lead the profession to guide beneficial PTG.

Curt Widhalm, LMFT is a member of the California Association of Marriage and Family Therapists Ethics Committee and an adjunct professor of Psychotherapy Law & Ethics at California State University Northridge. The opinions reflected in this paper are his own and do not reflect the opinions or stances of any other organizations.

References:

American Counseling Association. (2014). ACA Code of Ethics. Alexandria, VA: Author.

American Psychiatric Association. (2020). Opinions of the Ethics Committee on the Principle of Medical Ethics with Annotations Especially Applicable to Psychiatry 2020 edition. Washington, DC: Author.

American Psychological Association. (2018). Demographics of the U.S. psychology workforce: Findings from the 2007-16 American Community Survey. Washington, DC: Author.

Baker, M.J., George, D.R. & Kauffman, G.L. Navigating the Google Blind Spot: An Emerging Need for Professional Guidelines to Address Patient-Targeted Googling. J GEN INTERN MED 30, 6–7 (2015). https://doi.org/10.1007/s11606-014-3030-7

DiLillo, D., & Gale, E. B. (2011). To google or not to google: Graduate students’ use of the internet to access personal information about clients. Training and Education in Professional Psychology, 5(3), 160-166. https://doi.org/10.1037/a0024441

Eichenberg, C., & Herzberg, P. Y. (2016). Do therapists google their patients? A survey among psychotherapists. Journal of Medical Internet Research, 18(1), e3. https://doi.org/10.2196/jmir.4306

Ferro, A. (2016). People, characters, holograms. In Psychoanalysis, identity, and the internet: Explorations into cyberspace (pp. xv–xxii). New York: Routledge.

Ginory, A., Sabatier, L. M., & Eth, S. (2012). Addressing therapeutic boundaries in social networking. Psychiatry: Interpersonal and Biological Processes, 75(1), 40- 48. https://doi.org/10.1521/psyc.2012.75.1.40

Lehavot, K., Barnett, J. E., & Powers, D. (2010). Psychotherapy, professional relationships, and ethical considerations in the Myspace generation. Professional Psychology: Research and Practice, 41(2), 160-166. https://doi.org/10.1037/ a0018709

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