AUTHOR PREPRINT – MAY DIFFER FROM FINAL PUBLICATION Social media and clinical psychology: Friend or foe? Summary: The growth of social media introduces personal and professional benefits, risks and opportunities for those researching, training and working in clinical psychology. This article raises awareness of these issues, and makes suggestions for using these networks professionally, ethically and successfully. Fleur-Michelle Coiffait Trainee Clinical Psychologist and Psychology Postgraduate Affairs Group (PsyPAG) PsyPAG Chair Elect and Division of Clinical Psychology Representative University of Edinburgh and NHS Lothian School of Health in Social Science Teviot Place, Edinburgh EH8 9AG
[email protected] Kirsten Bartlett PhD Researcher, Associate Lecturer and PsyPAG British Psychological Society Ethics Committee Representative Sheffield Hallam University
[email protected] David J. Houghton Lecturer in Marketing Birmingham Business School University of Birmingham
[email protected] Jenna Condie Lecturer in Psychology, PhD Researcher, Vice-Chair North West England BPS Branch, and PsyPAG Information Officer University of Salford
[email protected]
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AUTHOR PREPRINT – MAY DIFFER FROM FINAL PUBLICATION Social media (SM) refers to communication platforms including online forums and social networking sites (SNS), such as Facebook and Twitter. Almost half of UK internet users have a social network profile, a figure that has doubled since 2007 (OfCom, 2010). Of these SNS users, 90% have a registered Facebook profile, making it the most popular SNS in the UK (OfCom, 2010). However, with such ubiquitous SNS use, practitioners face potential risks when using these sites. Clinical psychologists are required by the Health Professions’ Council (HPC) standards of proficiency, conduct, performance and ethics to act in a professional manner at all times (HPC, 2008; 2009a). Trainee clinical psychologists undertaking HPC accredited training programmes must adhere to their guidance on conduct and ethics for students (HPC, 2009b). McKenzie and Fawns (2011) suggest that clinical psychology trainees should avoid posting information on SNS due to the potential risk to their perceived professionalism. This article aims to present a wider view of both the benefits of using SM and the challenges to professionalism for those working in clinical psychology at all levels. First, we identify the appeal of SM, highlighting aspects with particular relevance to clinical psychology. Second, we outline a number of potential issues with the nature of SM that may threaten professional identities, and highlight the dearth of advice presently offered by professional bodies. Third, we argue that trainee and qualified clinical psychologists should not be deprived of the benefits offered by SM and suggest ways to manage an online presence in order to enjoy the benefits and minimise issues that may affect professional roles. The appeal of computer-mediated communication and social media SNS allow users to connect to and view information about others, traverse a list of network connections, hold synchronous and asynchronous conversations, share photos and videos, and build and maintain social relationships (Boyd & Ellison, 2007; Ellison et al., 2007). The social connectivity and social reinforcement of these features encourages users to continually return to check the latest developments (Burke et al., 2009). These aspects of SM make it well placed to engage with the
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AUTHOR PREPRINT – MAY DIFFER FROM FINAL PUBLICATION public, raise awareness of psychological wellbeing and promote an accurate understanding of the clinical psychology profession, and psychology more generally. Self-disclosure of information can also have a positive influence on individual health and wellbeing. For example, Ko & Kuo (2009) found that self-disclosure via blogging led to increased subjective wellbeing due to increases in social capital creation and maintenance as well as self-perceived social integration. Furthermore, disclosure can result in improved affect and a decrease in use of healthcare services (Smyth, 1998). Individuals who have experienced stigma and felt marginalised can more easily connect with similar others in online environments encouraging the development of self acceptance and the confidence to ‘come out’ about information previously kept secret (McKenna & Bargh, 1998). Disclosure in online communities such as Facebook can also benefit those initially low in self-esteem to connect with others (Steinfield, Ellison & Lampe, 2008). Potential benefits of using social media for clinical psychologists SM offer a number of other features that may appeal to clinical psychologists (Johnstone, 2011). For example, the ability to create pages dedicated to causes, companies and events may encourage sharing of relevant up to date information, or the ability to communicate with peers through group messaging to promote social support. An increasing number of psychologists, academics, health organisations, think tanks, charities and government departments currently publish information via SM feeds. Clinical populations can benefit from SM and mental health service providers are increasingly using SM as an innovative tool for information dissemination, aftercare, and engaging with hard to reach populations (NHS Confederation, 2011). For example, the Lincoln Social Computing Research Centre is currently investigating the effectiveness of implementing computerised CBT via a social network1. There is great potential for SM to allow clinical psychologists to connect with and support service-users who are isolated due to geographical, psychological or other 1
research.blogs.lincoln.ac.uk/2010/04/08/ epsrc-funds-lincoln-research-into-cognitive-behavioural-therapy-andsocial-networks/
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AUTHOR PREPRINT – MAY DIFFER FROM FINAL PUBLICATION reasons. SM may be particularly useful for those ‘in need of care but averse to receiving it’ (NHS Confederation, 2011), such as young adults who are looked after or accommodated or those with chronic health conditions. For example, individuals with Cystic Fibrosis are known to be at risk of developing mental health issues as they often struggle to meet others because of their condition, and reportedly find such support beneficial (Platten, 2011). Other platforms like Twitter, LinkedIn and Mendeley are available to professionals to connect with each other, encouraging information sharing and partnerships. However, each SNS has specific advantages, for example Facebook encourages the development of interactions amongst connected members, whereas Twitter provides a public ‘micro-blog’ format that can offer an efficient means of gaining an overview of news and current research. This can be a useful tool for broadcasting up-to-date information to an open audience, such as research news, events, jobs, funding opportunities and policy developments. The restrictive format of Twitter (140 character limit) may be particularly appealing to those working in clinical psychology as an efficient way of keeping up-to-date with current research, thus informing evidence based practice. SM could also facilitate a sense of professional identity for those working in clinical psychology through online communication with peers based in multi-disciplinary teams, distant research departments or geographically remote areas. The ‘#PhDchat’ hashtag2 used on Twitter is one example of such a community that allows PhD students from all disciplines and locations to share thoughts, ideas and other information. #PhDchat has a group moderator who collates conversations and resources shared by the PhD community onto a wiki (a webpage that allows users and site administrators to delete, add or modify content). A similar community could be developed for those in clinical psychology to share ideas, discuss and collaborate.
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A hashtag - denoted by the ‘#’ symbol - is used to mark keywords and topics on a particular theme in Twitter conversations that are easily searchable
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AUTHOR PREPRINT – MAY DIFFER FROM FINAL PUBLICATION Potential challenges of using social media for clinical psychologists Despite the advantages of SM there are several challenges to information and identity management when using them. The ability for users to generate the content that contributes to such services can pose several problems around information control, accuracy and validity of posts. It is exceptionally easy to share information or publish claims that may not be verified. On Facebook for example, other users, including friends can comment on posts. Both Facebook and Twitter allow users to ‘tag’ each other, and although there are exceptions, such as the ClinPsy.org.uk online wiki and forum, where content is overseen and moderated by a team of qualified clinical psychologists, wikis often allow anyone to contribute to the information stored without any quality control. The ease of information sharing in SM can make it difficult to manage potentially revealing personal information and misinformation posted by others that could result in damage to reputations (Solove, 2007). In Facebook, a comment posted by a ‘friend’ on an individual’s profile can be deleted by both users. A comment posted on an individual’s profile can be deleted by the owner of the profile or the poster of the information. However, an individual has no control over comments made about them by someone on another’s profile. Even when it is possible to edit information written by others, it is normally a post-hoc procedure, and the delay between recognition and action may mean it has been in the public domain for a period of time. In Twitter, a comment made about a specific individual can be ‘tagged’ using the @ symbol, which allows for those comments to be easily searched for and show up on that person’s profile. Abusive or inappropriate comments made by other users can be reported, but an individual cannot necessarily delete or remove posts made about them by others. In a wiki or online forum, site administrators can delete content, but it could be several days or weeks before it is spotted and more time before they are removed. It is therefore crucial to manage posts and if misinformation, abusive content or libellous comments are spotted, and are outside the user’s control, they should be reported to administrators. SM sites such as Twitter and Facebook do not have an obligation to check posts for quality or content ,and in America are protected under section 230 of the Communications Decency Act (CDA). In the UK, the issue was highlighted by a 5
AUTHOR PREPRINT – MAY DIFFER FROM FINAL PUBLICATION case involving Demon Internet, an internet service provider, which failed to remove defamatory content after it was brought to its attention. In this case Demon Internet would not have been liable if it had no knowledge of the defamatory material but once it had been brought to its attention it was made liable as the ‘publisher’3. A case that further illustrates this point was heard in the UK High Court in 2006. It was one of the first cases where a private individual sued another individual without involving the internet service provider and resulted in a college lecturer being ordered to pay damages to an MP for making defamatory statements in an online forum4. At present, it is therefore up to the individual to maintain their online presence, and if necessary take action to manage any misinformation posted about themselves. However, one of the greatest challenges facing professionals using SM and online platforms is how to manage their personal and professional identities online. It has been suggested that we all have a ‘nexus of multimembership’ - we define who we are by the way we reconcile our various group memberships (Wenger, 1998). McKenzie and Fawns (2011), for example, highlight that clinical psychology trainees have multiple identities, including postgraduate student, clinical practitioner, family member, partner and so on. Although professional and personal identities are often described as distinct, they invariably overlap (Nystrom, 2009) and the boundaries between these different roles can become blurred. In a digital age with information so freely available, it seems unrealistic to expect personal and professional identities to remain completely separate. McKenzie and Fawns (2011) suggest that this could be problematic for clinical psychology trainees and called for trainees to maintain a degree of integrity in online environments by avoiding posting anything that would be inappropriate for an employer, colleague, supervisor, lecturer or client to see. This could be extended further to all practitioners, regardless of their seniority. Although these issues are not limited to online environments, controlling what is posted and what happens to personal data on sites such as Facebook can be difficult to negotiate. Furthermore, the 3
For an overview see: http://www.jisclegal.ac.uk/LegalAreas/HostingLiability/ISPLiabilityEssentials.aspx See: http://www.guardian.co.uk/media/2006/mar/23/digitalmedia.law and: http://www.bailii.org/ew/cases/EWHC/QB/2006/860.html 4
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AUTHOR PREPRINT – MAY DIFFER FROM FINAL PUBLICATION record permanence of this data means that potentially any indiscretion may be searchable forever (Solove, 2007). A common concern with SNS, like Facebook, is the potential for information to leak to unintended recipients (Binder et al., 2009; Joinson et al., 2011). This becomes a particular problem when SM are used for both professional and personal purposes. Information may be redistributed by co-owners without seeking prior permission (McKenzie & Fawns, 2011). Actions such as these can result in feelings of betrayal or humiliation (Houghton & Joinson, 2010), and the professional consequences for clinical psychologists may go even further. As social communication technologies expand, clinical psychologists need to consider their own online presence and communication. Specifically, how different roles and identities can be reconciled against the expansion of both personal and professional information shared online. Reflexive practice encouraged during clinical psychology training can appear to focus on maintaining rigid boundaries between professional and personal identities. However, in a digital age, perhaps reflection should also acknowledge the increasingly inevitable overlap between professional and personal identities and how this may be managed. Although those working in clinical psychology are likely to be aware of, and to explicitly discuss, issues of boundaries and roles, it is crucial to remain aware of professional and ethical commitments in both spheres and how they may influence one another. Guidance from professional bodies The challenges mentioned above are not comprehensive, but are particularly relevant for professions involving sensitive relationships (i.e. healthcare, education, justice) in the digital age. The question of how to integrate personal identities with professional identities and control shared personal information will need to be considered in a number of arenas. To date, scarce guidance has been offered regarding the role of a practicing psychologist’s professional identity within personal online environments. The little literature that exists is predominantly authored by American psychologists in private practice via their own blogs and online articles (cf. Kolmes, 2009a; 2009b; Grohol, 2010; Scarton, 2010). However, a special issue of Professional Psychology: 7
AUTHOR PREPRINT – MAY DIFFER FROM FINAL PUBLICATION Research and Practice published in December 2011 comprehensively explored clinical, legal, regulatory and other issues associated with an electronic age, highlighting the importance for psychologists to reflect on how this affects our research, practice and conduct (cf. Baker & Bufka, 2011). Currently, neither the British Psychological Society (BPS) nor the American Psychological Association (APA) have specific guidance focusing on online behaviour. However, the BPS and the Division of Clinical Psychology (DCP) are developing guidelines at the time of writing. More general guidance on conduct and professional behaviour exists in the form of the BPS Code of Ethics and Conduct (BPS, 2009), HPC Standards of Conduct, Performance and Ethics, and the DCP Professional Practice Guidelines (DCP, 1995). However, these do not yet acknowledge or address issues specifically associated with the use of SM. In contrast, the British Medical Association (BMA) and Nursing and Midwifery Council (NMC) have recently produced guidelines to address SM (cf. British Medical Association, 2011; Nursing & Midwifery Council, 2011). The NMC guidelines were produced in response to an increasing number of fitness to practice cases involving the use of SNS, and highlight the concern healthcare professions have regarding the responsible use of SM. Their suggestions are relevant to all health professionals and include recommendations such as using different SM sites to keep personal and professional accounts separate and keeping abreast of privacy settings. Both the NMC and BMA guidelines suggest that ‘friend’ requests from patients via Facebook should not be accepted. However, whereas the NMC suggests that they should be ignored, psychologists may want to consider the impact of ignoring such a request, bearing in mind that psychologists are often working with complex and potentially vulnerable individuals within a therapeutic context, whereas nurses engage in a very different type of relationship with their patients. Importantly, the BMA makes the point that as medical students have responsibilities that are different to students of other subjects, they should be more aware of their online presence. Clinical psychology trainees may also benefit from explicit reflection on
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AUTHOR PREPRINT – MAY DIFFER FROM FINAL PUBLICATION how their online presence may impact on their chosen profession and future endeavours. In the absence of official guidance it is vital for psychologists and others with a professional code of conduct to be aware of how their information is shared online and may be perceived by others. Clinical psychologists, trainees and educators need to keep up to date with SM as this will put them in a stronger position to exploit its potential for assisting in reaching clinical populations and collaborating with colleagues. However, there also needs to be awareness of how engaging in SM could expose you to the effects of misinformation, criticism or accusations of unprofessional conduct. For example, posts from others on a psychology professional’s Facebook wall could be perceived as offensive and result in accusations of unprofessional conduct. Currently few, if any, examples of misinformation that have resulted in a professional misconduct case exist. However, it is naïve to presume that this cannot and will not happen. Whilst we do not advocate the fear of reprisal being used to encourage safe online behaviour, we do encourage clinical psychology professionals to consider the possible consequences of allowing others to comment freely. Appropriate privacy settings are paramount when there are possible conflicts in the perception of what constitutes ‘professional’ conduct held by different audiences. Although the context and situations of each individual will be unique and require handling in different ways, following are a few suggestions to keep in mind when interacting in SNS. Suggestions for promoting safe and professional online conduct It is important to note that we do not claim to be ‘experts’ in SM practice. However, our experience and extensive reviews drawn from areas including clinical psychology, information systems, media psychology, the psychology of communication and practical experience as early adopters and users of SM in professional fields, gives us a solid grounding on which the following ideas are based. Individually and as a group we have conducted research on boundary and information management within SNS, as well as issues of privacy (cf. Houghton & Joinson, 2010; Houghton & Joinson, 2012; Joinson et al., 2011) and have provided advice to both the DCP and the BPS on the development of guidelines for psychologists. Through links with the BPS Ethics 9
AUTHOR PREPRINT – MAY DIFFER FROM FINAL PUBLICATION Committee we have discussed the development of guidelines with the NMC and in developing the following suggestions we have drawn on the guidelines published by the BMA. The points presented below are based on how we manage our online presence and may help clinical psychologists and trainees to maintain, manage and share information online. • Think about what information you share online, where you share it, who might see it and how it may be perceived by different people (e.g. managers, colleagues, clients). • Bear in mind the permanence of information published online. • Familiarise yourself with the privacy settings of any sites that you use and keep up to date with these as they are regularly revised. • Consider separating personal and professional SNS accounts. For example, using different SNS for different purposes. • Restrict access to your personal account to only those whom you wish to see this side of you. • Remain aware that you represent psychology as a profession in all spheres. • Look after your digital identity and take control of information about you online by entering your name into a search engine to see what others can find about you. Summary and conclusions Clinical psychologists and other professions working with vulnerable groups occupy multiple and sometimes conflicting roles. Psychologists are experienced at managing such role conflicts and boundary issues in offline contexts, but with increased connectivity and activity online, these boundaries may be challenged. With increasing numbers of concerns being raised regarding the way health professionals present themselves online, it is time for clinical psychology to join in the discussion and openly investigate how the impact of multiple identities and role conflicts can be managed.
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AUTHOR PREPRINT – MAY DIFFER FROM FINAL PUBLICATION References Baker, D.C. & Bufka, L.F. (2011). Preparing for the telehealth world: Navigating legal, regulatory, reimbursement and ethical issues in an electronic age. Professional Psychology: Research and Practice, 42(6), 405–411. Binder, J., Howes, A. & Sutcliffe, A. (2009). The problem of conflicting social spheres: Effects of network structure on experienced tension in social network sites. Paper presented at the CHI 2009, Boston, MA, USA. British Medical Association (2011). Using social media: Practical and ethical guidance for doctors and medical students. Retrieved 28 July 2011 from bma.org.uk/images/socialmediaguidancemay2011_tcm41-206859.pdf British Psychological Society (2006). Core competencies - Clinical psychology: A guide. Leicester: Author. Boyd, D. M. & Ellison, N. B. (2007). Social network sites: Definition, history, and scholarship. Journal of Computer-Mediated Communication, 13(1), 210–230. Burke, M., Marlow, C. & Lento, T. (2009). Feed me: Motivating newcomer contribution in social network sites. Paper presented at the CHI 2009 Conference, Boston, MA, USA. Division of Clinical Psychology (1995). Professional practice guidelines. Leicester: British Psychological Society. Ellison, N., Steinfield, C. & Lampe, C. (2007). The benefits of Facebook friends: Social capital and college students' use of online social network sites. Journal of Computer-Mediated Communication, 12(3), 1143–1168. Grohol, J.M. (2010). Google and Facebook, therapists and clients. World of Psychology. Retrieved 28 July 2011 from psychcentral.com/blog/archives/2010/03/31/google-and-Facebook-therapistsand-clients/ Health Professions Council (2008). Standards of conduct, performance and ethics. London: Author. Health Professions Council (2009a). Standards of proficiency: Practitioner psychologists. London: Author. Health Professions Council (2009b). Guidance on conduct and ethics for students. London: Author. Hennig-Thurau, T., Malthouse, E., Friege, C., Gensler, S., Lobschat, L., Rangaswamy, A. & Skiera, B. (2010) The impact of new media on customer relationships. Journal of Service Research, 13, 311–330. Houghton, D.J. & Joinson, A.N. (2010). Privacy, social network sites, and social relations. Journal of Technology in Human Services, 28(1), 74–94. Johnstone, L. (2011). Media column. Clinical Psychology Forum, 225, 49-50. Joinson, A.N., Houghton, D.J., Vasalou, A. & Marder, B.L. (2011). Digital crowding: Privacy, self-disclosure and technology. In S. Trepte & L. Reinecke (Eds.), Privacy online: Perspectives on privacy and self-disclosure in the social web (pp. 31–44). Heidelberg and New York: Springer. Ko, H., & Kuo, F. (2009). Can blogging enhance subjective well-being through selfdisclosure? CyberPsychology & Behavior, 12(1), 75–79. Kolmes, K. (2009a). Managing Facebook as a mental health professional. Articles for Clinicians Using Social Media. Retrieved 28 July from drkkolmes.com/2009/06/08/managing-facebook-as-a-mentalhealth-professional/
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AUTHOR PREPRINT – MAY DIFFER FROM FINAL PUBLICATION Kolmes, K. (2009b). You may have a major depressive disorder. Mind if I tweet that? Articles for Clinicians Using Social Media. Retrieved 28 July from drkkolmes.com/2009/11/03/ive-given-you-a-diagnosis-of-major-depressivedisorder-mind-if-i-tweet-that/ McKenzie, K. & Fawns, T. (2011). Social networking, identity and professionalism in clinical psychology. Clinical Psychology Forum, 221, 46–49. NHS Confederation (2011). Joining in the conversation: Social media and mental health services. Briefing 225. Retrieved 18 January 2012 from www.nhsconfed.org/Publications/Documents/ Joining_the_conversation_161111.pdf Nursing and Midwifery Council (2011). Social networking sites. Retrieved 28 July 2011 from nmc-uk.org/Nurses-and-midwives/Advice-by-topic/A/Advice/Socialnetworking-sites/ Nystrom, S. (2009). The dynamics of professional identity formation: Graduates’ transitions from higher education to working life. Vocations and Learning, 2, 1–18. OfCom (2010). UK adults’ media literacy. Retrieved 28 July 2011 from stakeholders.ofcom.org.uk/binaries/research/media-literacy/adults-medialiteracy.pdf Platten, M.J. (2011). Mental health, self-esteem and quality of life of adults with cystic fibrosis and their use of an online discussion forum. Unpublished doctoral thesis, University of Edinburgh, UK. Scarton, D. (2010). Google and Facebook raise new issues for therapists and their clients. Washington Post. Retrieved 28 July 2011 from www.washingtonpost.com/wpdyn/content/article/2010/03/29/AR2010032902 942_pf.html Smyth, J.M. (1998). Written emotional expression: Effect sizes, outcome, types, and moderating variables. Journal of Consulting and Clinical Psychology 66, 174– 184. Solove, D.J. (2007). The future of reputation: Gossip, rumor, and privacy on the internet. New Haven: Yale University Press. Steinfield, C., Ellison, N. & Lampe, C. (2008). Social capital, self-esteem, and the use of online social network sites: A longitudinal analysis. Journal of Applied Developmental Psychology, 29(6), 434–445. Wenger, E. (1998). Communities of practice: Learning, meaning and identity. Cambridge: Cambridge University Press.
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