Therapistsâ•Ž Willingness to Access Client Social Media Accounts in the Context of Suicide Risk

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Therapists’ Willingness to Access Client Social Media Accounts in Therapists’ Willingness to Access Client Social Media Accounts in

the Context of Suicide Risk the Context of Suicide Risk

Jacob A. Vermeersch

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LOMA LINDA UNIVERSITY

School of Behavioral Health

in conjunction with the

Faculty of Graduate Studies

____________________

Therapists’ Willingness to Access Client Social Media Accounts in the Context of Suicide Risk

Jacob A. Vermeersch

____________________

A Dissertation submitted in partial satisfaction of

the requirements for the degree

Doctor of Philosophy in Clinical Psychology

____________________

June 2021

Jacob Adam Vermeersch

iii

Each person whose signature appears below certifies that this dissertation in his/her

opinion is adequate, in scope and quality, as a dissertation for the degree Doctor of

Philosophy.

, Chairperson

Janet Sonne, Emerita Professor of Psychology

Hector Betancourt, Distinguished Professor of Psychology

Stephanie Goldsmith, Licensed Clinical Psychologist

Jenny H. Lee, Assistant Clinical Professor of Psychology

ACKNOWLEDGEMENTS

I would first like to extend my deepest gratitude to Dr. Sonne, whose knowledge,

experience, wisdom, and encouragement propelled me forward during times where it was

difficult to do so for myself. I also owe so much to my committee members, Drs.

Goldsmith, Lee, and Betancourt, who always made themselves available and approached

my project with the same level of care and dedication as they did when they were my

professors or supervisors (which feels so long ago now). I met all four of these wonderful

folks the beginning of my doctoral program, and I am so grateful to have had the

opportunity to come full circle with them in my corner.

I would like to thank my best friends, Ryan, Tyler, Jacob, Danny, Mike, Chris,

and the Nicks. I admire and respect every one of you, and you all inspired me at one point

or another to keep my nose to the grindstone, even if it was just so I can take you all out

for dinner when I get my first job. I am sure you will hold me to that.

Finally, I must thank my family – Mom, Dad, Ethan and Emma – for their

unwavering love and support, not only during this project and my schooling, but

throughout my entire life. This project is, in many ways, the culmination of everything

you have given me and everything I have learned from each of you. I truly could not have

done this without you all.

CONTENT

Approval Page .................................................................................................................... iii

Acknowledgements ............................................................................................................ iv

List of Figures .................................................................................................................. viii

List of Tables ..................................................................................................................... ix

List of Abbreviations ...........................................................................................................x

Abstract .............................................................................................................................. xi

Chapter

1. Literature Review.....................................................................................................1

Introduction ........................................................................................................1

Growth of Social Media .....................................................................................2

Expansion of Psychologists’ Presence in the Digital Space ..............................3

Communication with Potential and Existing Clients ...................................3

Disseminations of Psychoeducation ............................................................4

Online Assessment and Intervention ...........................................................5

Suicide as a Public Health Crisis .......................................................................5

Standards of Care for In-Person Suicide Risk Assessment and

Prevention for Psychologists..............................................................................7

Legal and Ethical Duty to Protect ................................................................7

Conflicts Between Ethical and Legal Standards ........................................10

Barriers to In-Person Suicide Risk Assessment and Intervention .............12

Clients’ Expressions of Suicidality on Social Media .................................15

Ethical Implications of Digital Suicide Risk Assessment and

Intervention for Psychologist .....................................................................19

APA General Ethical Principles ...........................................................20

APA Guidelines for the Practice of Telepsychology ...........................24

Ethical Standards of Other Mental Health Professions........................25

Potential Benefits of Social Media-Informed Risk Assessments and

Digital Welfare Checks ..............................................................................27

Social Media-Informed Risk Assessment ............................................28

Digital Welfare Checks ........................................................................29

Research Regarding Therapist Access and Use of Client Social

Media Information .....................................................................................32

Online Client Searches: Frequencies, Reasons, and Disclosures

to Clients ..............................................................................................32

Therapist Characteristics Affecting Willingness to Conduct

Online Client Searches .........................................................................35

Therapist Age .................................................................................35

Therapist Gender ............................................................................37

Therapist Theoretical Orientation ..................................................37

Therapist Reliance on General Ethical Principles .........................38

Rationale of Current Research and Hypotheses...............................................43

Hypotheses .......................................................................................................44

Hypothesis 1.........................................................................................44

Hypothesis 2.........................................................................................45

Hypothesis 3.........................................................................................45

Hypothesis 4.........................................................................................45

Hypothesis 5.........................................................................................46

Hypothesis 6.........................................................................................46

Hypothesis 7.........................................................................................47

2. Methods..................................................................................................................49

Participants .......................................................................................................49

Measures ..........................................................................................................49

Social Media-Informed Risk Assessment Vignette (Vignette A) ..............49

Digital Welfare Check Vignette (Vignette B) ...........................................50

General Ethical Principles Questionnaire ..................................................50

Vignette Follow-Up Questionnaire ............................................................51

Therapist Characteristics Questionnaire ....................................................51

Procedures ........................................................................................................52

Initial Analyses ................................................................................................54

Invalid Analyses...............................................................................................54

Missing Data Analysis .....................................................................................66

3. Results ....................................................................................................................56

Sample Characteristics .....................................................................................56

Frequency Analyses and Likelihood Comparisons..........................................59

vii

Multiple Linear Regression Analyses ..............................................................56

Results for Social Media-Informed Risk Assessment .....................................61

Results for Digital Welfare Check ...................................................................64

4. Discussion ..............................................................................................................66

Current Study ...................................................................................................66

Discussion of the Results of the Hypotheses ...................................................67

Implications for Clinical Work ........................................................................72

Limitations and Future Directions ...................................................................75

References ..........................................................................................................................77

Appendices

A. Listserv and Snowball Email Recruitment Notice to Participants .....................84

B. Informed Consent Form ......................................................................................86

C. Vignette A (Social Media-Informed Risk Assessment) .....................................89

D. Vignette B (Digital Welfare Check) ..................................................................90

E. General Ethical Principles Questionnaire ..........................................................91

F. Vignette Follow-Up Questionnaire ....................................................................93

G. Therapist Characteristics Questionnaire ............................................................94

H. Listserv Recruitment Sites .................................................................................98

I. Social Media (Facebook) Recruit Site ...............................................................99

viii

TABLES

Tables Page

1. Demographic Data for Respondents ......................................................................57

2. Results of Frequency Analysis of Participants’ Likelihood Ratings .....................60

3. Results of Multiple Linear Regression Analysis for Social Media-

Informed Risk Assessment ....................................................................................63

4. Results of Multiple Linear Regression Analysis for Digital Welfare Check.........65

ABBREVIATIONS

APA American Psychological Association

SM Social Media

US United States

CDC Centers for Disease Control and Prevention

VA Veteran’s Administration

ORS Oregon Revised Statutes

OHA Oregon Health Authority

NASW National Association of Social Workers

ACA American Counselor’s Association

ApA American Psychiatric Association

CNN Cable News Network

CPA Canadian Psychological Association

CCEP Canadian Code of Ethics for Psychologists

CA California

M Arithmetic Mean

SD Standard Deviation

MLR Multiple Linear Regression

CBT Cognitive Behavioral Therapy

IRB Institutional Review Board

DBT Dialectical Behavior Therapy

REBT Rational Emotive Behavior Therapy

ABSTRACT

Therapists’ Willingness to Access Client Social Media Accounts in the Context of

Suicide Risk

Jacob A. Vermeersch

Doctor of Philosophy, Graduate Program in Clinical Psychology

Loma Linda University, June 2020

Dr. Janet Sonne, Chairperson

The past two decades has seen a proliferation of social media use, leading to a

growing body of research on the potential utility for clinical contexts. In the current

study, we examine willingness of psychologists to utilize client social media to inform

suicide risk-assessment and risk-related treatment decisions, and the ethical principles

they used to guide their considerations. Participants were asked of the likelihood they

would engage in 1) a social media-informed risk assessment, where the therapist uses

client social media to inform their initial determination of risk level, and 2) a digital

welfare check, where the therapist accesses an at-risk client's social media page to

determine if they are in immediate danger and require further protective measures.

Participants’ likelihood of engaging in these behaviors was assessed using two fictional

clinical vignettes. The ethical principles they used in their deliberations were assessed

using the General Ethical Principles Questionnaire, in which participants rated the

relative contribution of each general ethical principle (Beneficence and Nonmaleficence,

Respect for Peoples' Rights and Dignity, Integrity, Justice, and Fidelity and

Responsibility) to their responses on the vignettes. Therapist factors including

xii

professional status (licensed vs. in-training), digital literacy, and theoretical orientation

were examined in terms of how they influenced likelihood ratings for each vignette.

Overall, most participants reported being unlikely to engage in either a social media-

informed risk assessment or a digital welfare check. Results also indicated participants

were more likely to conduct a digital welfare check than a social media-informed risk

assessment. Interestingly, relative value placed on Beneficence positively predicted

likelihood to engage in both forms of social media checks, and Respect for Peoples’

Rights and Dignity negatively predicted likelihood to engage in a digital welfare check,

but not a social media-informed risk assessment. Professional status, digital literacy and

identification with any specific theoretical orientation did not predict likelihood to engage

in either form of therapist accessing clients’ social media. We conclude with a discussion

of how psychologists can effectively and ethically incorporate social media into their

practice and potential implications for the development of future ethical standards and

guidelines related to digital practice.

CHAPTER ONE

Literature Review

Introduction

The proliferation of social media (SM) has propelled society into a new age of

digital communication, leading social scientists, researchers, and clinicians to develop

new ways to utilize the vast amount of data provided by SM content. SM offers users a

platform to share their thoughts, emotions, behaviors, and experiences with the public.

Researchers and clinicians have only just begun to explore the potential uses of SM as

one of the richest sources of information regarding human language and behavior. As we

continue to learn more about what SM users choose to post and why, as well as the level

to which individuals’ posts are indicative of their psychosocial functioning, there is an

opportunity for mental health providers to use this growing knowledge-base to develop

novel clinical approaches and interventions unique to this increasingly digital age.

In the present study, we examine clinicians’ attitudes regarding using SM to

preserve client safety. Specifically, we examine participants' likelihood to engage in two

different ways of using client SM data to inform treatment decisions related to client risk

of suicide: (a) social media-informed risk assessment and (b) digital welfare checks. We

also examine whether certain clinician demographic and professional characteristics

influence that likelihood. This introduction begins with a general discussion on the

growth of SM the expansion of psychology in the digital sphere, particularly regarding

online dissemination of psychoeducation, online assessment and intervention, and online

communication with potential and existing clients. A brief review of current trends in

suicide rates and a discussion of various clinical, ethical, and legal considerations related

to the management of suicidal patients follow. Next, some of the barriers and

shortcomings of current suicide risk assessment procedures are presented. A discussion

regarding the effects that the proliferation of SM has had on patterns of client disclosure

of suicidal ideation outside of therapeutic contexts comes next. Then, current aspirational

ethical principles and guidelines for psychologists, and ethical standards from other

mental health disciplines regarding the therapist’s accessing of clients’ SM are presented

and applied to the specific context of client suicidal risk. An argument is then offered for

clinicians’ use of at-risk clients’ SM information through (a) social media-informed risk

assessment and (b) digital welfare checks. The introduction concludes with a review of

research findings related to therapists’ accessing and use of clients’ SM, as well as

therapist characteristics that predict those behaviors, noting the dearth of literature on

therapist online behavior in the context of client suicide risk.

Growth of Social Media

SM use has exploded over the past two decades, leading to its emergence as a

burgeoning arena for psychosocial research. According to a series of surveys conducted

by the Pew Research Institute from 2005 to 2019, only 5% of American adults reported

using at least one social media platform in 2005. By 2011, half of American adults

reported using at least one social media platform; this number now sits at 72% as of

2019. This increase has been observed in US adults in all age groups. The largest increase

has been among US adults aged 18-29, with SM use in this age bracket increasing from

7% in 2005 to 90% in 2019. The percentage of adults aged 30-49 who report using at

least one SM platform increased from 6% in 2005 to 82% in 2019. SM use among older

adults has also increased substantially over the same time period, from 4% in 2005 to

69% in 2019 for US adults aged 50-64, and from 3% in 2005 to 40% in 2019 for US

adults 65 and older. Furthermore, SM use has become a staple in the daily routine of US

adults; three quarters of Facebook users and 63% of Instagram users report using the

platform at least once daily (Pew Research Institute, 2019).

Expansion of Psychologists’ Presence in the Digital Sphere

Given the rapid expansion of SM users and the evolving manner in which SM is

used for communication and personal expression, an evaluation of how SM may be

utilized to improve clinical practice is warranted. In what ways can psychologists utilize

SM for clinical purposes, while adhering to ethical standards and principles? The answer

to this question depends on a clinicians' reason for venturing into the digital sphere.

Psychologists can improve and expand their services by using SM and the internet for

four purposes: (a) to communicate with current and prospective clients, (b) to disseminate

psychoeducational material, (c) to access information that may inform psychosocial

status/functioning assessment and treatment decisions, and (d) to deliver interventions in

clinical and forensic settings. Each of these are discussed below.

Communication with Potential and Existing Clients

An increasing number of psychologists are developing websites to facilitate their

practice, many of which are readily available when prospective clients search for various

selection factors (Kolmes & Taube, 2016). Additionally, platforms like

PsychologyToday’s “Find a Therapist" allow individuals interested in or seeking mental

health care to enter their location and be provided with the names of all of the therapists

within a predetermined distance who have a profile on PsychologyToday. Therapists can

use such platforms to identify their specialty areas, theoretical orientation, accepted

insurance carriers, fees, experience working with clients of diverse social groups based

on age, gender, gender identity, race, ethnicity, culture, nation origin, religion, sexual

orientation, disability, and language to name a few, and their own demographics.

Individuals in search of a therapist have the option to sort and filter their options based on

these factors. Many therapists on PsychologyToday also provide information regarding

their education background, photos of their office, and a description of their services and

clinical style. Researchers have also demonstrated that clinicians often search for their

clients on the internet to obtain relevant contact information (Kolmes & Taub, 2014).

Further, many psychologists use e-mail and texting to coordinate services with their

clients (Mahue & Gordon, 2000).

Dissemination of Psychoeducation

SM also represents a new platform in which psychologists can disseminate

psychoeducation on a wide range of mental health topics. For example, many users on

YouTube post psychoeducation videos for the general public to access. Though there still

exists a significant amount of misinformation on YouTube regarding topics related to

mental health (Gordon, Miller, & Collins, 2015), providing high-quality, empirically-

supported psychoeducational material through SM can increase access to mental health

services and information among ethnic minorities, as well as reduce stigma related to

help-seeking (Lam, Tsiang, & Woo, 2017). Pursuant to the goal of bridging the gap

between psychology and the online world, the American Psychological Association

currently has a YouTube channel (with 24,100 subscribers), where it runs a video series,

"Speaking of Psychology," in which psychologists of varying specialties give lectures on

mental health topics.

Online Assessment and Intervention

Psychological assessments and interventions have made their way into the digital

sphere largely through the increased use of telehealth services. The APA defines

telehealth as “the provision of medical care services using technological modalities in

lieu of, or in addition to, traditional face-to-face methods.” The term telehealth also

encapsulates telepsychology and tele-mental health. Telepsychology provides the

opportunity for individuals to receive mental health care that otherwise may have been

inaccessible (Hopps, Pepin, & Boisvert 2003). For example, individuals with physical

disabilities may not be able to attend in-person sessions. Also, the COVID-19 pandemic

has made digital access to services all the more important.

Investigators have examined the efficacy, accuracy, and ethical implications of

conducting assessments through technology compared to face-to-face. Schopp,

Johnstone, & Merrell (2000) found no significant group differences between a sample of

49 clients who underwent neuropsychological tele-assessment and matched controls in

their satisfaction and interpersonal ratings of the tele-assessment session. More recent

studies have examined the ethics of online assessment, with authors identifying multiple

aspects of telehealth assessment that warrant special ethical considerations (Fisher &

Fried, 2003; Luxton, Pruitt, & Osenbach, 2014). Furthermore, in the midst of the

COVID-19 pandemic, the APA published an article providing recommendations for tele-

assessment, addressing issues such as test security, adaptations to testing protocol, data

quality, and the widening of confidence intervals (Wright, Mihura, Pade, & McCord,

2020). Some clinicians have raised concerns that, for some diagnoses (e.g., autism),

assessments restricted to online administrations may be ultimately invalid, and thus worse

than no assessment (Shropsire Live, 2020).

Some researchers have shown that telepsychology interventions produce

outcomes for clients that are comparable to face-to-face therapy (Mohr, Ho, Duffecy,

Reifler, Sokol, Burns, Jin & Siddique, 2012). Other studies have demonstrated that SM

can be used to supplement interventions for mental disorders such as major depression,

bipolar disorder, and schizophrenia, with favorable results (Naslund, Aschbrenner,

Marsch, McHugo, & Bartels, 2018; Lam, Tsiang, & Woo, 2017).

Research findings also suggest that suicide risk assessment and intervention may

be enhanced when supplemented with online resources. For example, investigators have

begun to explore different approaches to digitized risk assessment, describing various

implementations and protocols related to such assessments, as well as some associated

ethical issues (see e.g., Luxton, O'Brien, & Pruitt 2014). There is evidence for the

feasibility of augmenting traditional case monitoring services for Veterans with suicidal

ideation with a digital case monitoring application (Kasckow, Zickmund, Gurklis, Luther,

Fox, Taylor, Richmond, & Hass, 2016). The next three sections of this Introduction

outline the public health crisis revealed in suicide rates in the United States, discuss the

ethical and legal standards of care, and present common barriers to in-person suicide risk

assessment and intervention.

Suicide as a Public Health Crisis

The age-adjusted suicide completion rate in the United States increased 30% from

2000 to 2016, with rates climbing for all age groups among both men and women

(Centers for Disease Control and Prevention, 2017). This increase was particularly

significant for youth and young adults, specifically young women aged 10-14, young

women aged 15-24, and young men aged 15-24. Young women aged 10-14 expressed by

far the largest increase in suicide rates, jumping from 0.6 in 2000 to 1.7 in 2016 (a 183%

increase). Data from 2018 published by the CDC echoes these trends (Center for Disease

Control and Prevention, 2020). In 2018, 1.4 million Americans age 18 and older

attempted to die by suicide. Furthermore, 132 Americans died by suicide per day,

amounting to 48,344 suicide deaths that year, up from 42,773 in 2014. In 2018, suicide

was the tenth leading cause of the death in the United States, further solidifying its

designation as a national public health crisis, rather than a specialized issue reserved for

mental health clinicians (Center for Disease Control and Prevention, 2020).

Standards of Care for In-Person Suicide Risk Assessment and Prevention for

Psychologists

Legal and Ethical Duty to Protect

Given that the country has identified suicide as a public health issue, legal statutes

related to suicide prevention are in national and state law. For example, the Joshua

Omvig Veterans Suicide Prevention Act (2007) formally acknowledged that suicide

prevention amongst veterans is a pressing health issue, and put in place a comprehensive

suicide prevention program which has since been disseminated to VAs around the

country. Recently, various national health organizations statewide have increased their

partnership with the federal and state governments to develop suicide prevention policies.

In 2017, the CDC published Preventing Suicide: A Technical Package of Policy,

Programs, and Practices (CDC, 2017), which identifies empirically-supported strategies

to be considered in the development of federal and statewide suicide prevention

legislation. State laws and case precedence have also established the clinician’s

responsibility to competently assess risk and intervene appropriately to prevent client

suicide. In some states, clinicians are mandated to report a client at risk for suicide under

specific circumstances to appropriate authorities (e.g., Suicide Attempts by Minors,

Oregon law [ORS 441.750{1}{b}] requires hospital staff to report suicide attempts of

persons under 18 to OHA/Public Health). In the majority of states, therapists are legally

permitted to break confidentiality to ensure the safety of a suicidal patient (e.g.,

California Civil Code 56.10 and Evidence Code 1024). Further, some states require that

therapists-in-training complete specific coursework in the assessment and treatment of

suicidal clients as a prerequisite to licensure (e.g., California AB 89).

Specific to the field of psychology, the American Psychological Association

(APA) has ethical principles and standards that delineate best practice (APA, 2017). In

the context of in-person risk assessment and suicide prevention, several general ethical

principles and standards are relevant. Five aspirational ethical principles provide a

framework for the ethical navigation of risk situations: Beneficence and Nonmaleficence,

Fidelity and Responsibility, Integrity, Justice, and Respect for People’s Rights and

Dignity.

Arguably the most important ethical duty of a psychologist is the preservation of

client welfare, a duty that is clearly delineated in the general principle of Beneficence and

Nonmaleficence: "psychologists seek to safeguard the welfare and rights of those with

whom they interact professionally, and other affected persons" (APA, 2017, p. 3). The

preservation of a client’s life can be reasonably interpreted as a fundamental application

of this principle. When it is apparent that a client’s life may be in immediate danger, the

psychologist must take appropriate and proactive measures to mitigate this risk, through

standard-of-care procedures such as safety planning, consultation with colleagues and

supervisors, welfare checks, and voluntary or involuntary hospitalization.

Additional ethical principles inform suicide risk assessment and intervention. For

example, the principle of Fidelity and Responsibility refers to the psychologist’s duty to

establish and maintain a relationship of trust with clients. As such, psychologists "clarify

their professional roles and obligations, accept appropriate responsibility for their

behavior, and seek to manage potential conflicts of interest that could lead to exploitation

or harm" (APA, 2017; p. 4). The general ethical principle of Integrity states that

psychologists should "promote accuracy, honesty, and truthfulness in the science,

teaching, and practice of psychology" (APA, 2017, p.4), while the general principle of

Respect for People’s Rights and Dignity admonishes psychologists to “respect the dignity

and worth of all people, and the rights of individuals to privacy, confidentiality, and self-

determination” (APA, 2017; p. 5). A relevant application of these three principles in the

context of suicide risk assessment and intervention pertains to the informed consent

process. Ethical standards of care require that individuals undergoing psychological

assessment or treatment be fully informed regarding the nature of the services provided,

the roles and obligations of the provider, and the limits of confidentiality and privacy.

After understanding this information, patients must then decide whether to proceed with

the services as described. Rudd et al. (2009) argue that the informed consent process for

patients with histories of suicidal ideation and behavior should include a clear statement

regarding risks inherent in the services provided and the therapist’s procedures for

managing those risks.

The general principle of Justice also requires psychologists to "exercise

reasonable judgment and take precautions to ensure that their potential biases, the

boundaries of their competence, and the limitations of their expertise do not lead to unjust

practices" (APA, 2017; p 5). Clearly, in the domain of suicide risk assessment and

management, clinician competence is of crucial importance.

Enforceable ethical standards based on these aspirational principles define the

ethical standard of care for suicide risk assessment and intervention in clinical contexts.

Examples include: Standards 2.01 (Boundaries of Competence), 2.02 (Providing

Services in Emergencies), 2.03 (Maintaining Competence), 3.04 (Avoiding Harm), 3.09

(Cooperation with Other Professionals), 3.10 (Informed Consent), 4.01 (Maintaining

Confidentiality, 4.02 (Discussing Limits of Confidentiality), 4.05 (Disclosures), 4.06

(Consultations), 6.01 (Documentation of Professional and Scientific Work and

Maintenance of Records), 9.01 (Bases for Assessments), 9.02 (Use of Assessments), 9.03

(Informed Consent in Assessments, and 10.01 (Informed Consent to Therapy).

Conflicts Between Ethical and Legal Standards

Clinically navigating client suicide risk often presents the therapist with an

“ethical dilemma,” which the APA defines as “arising when two or more of the values

found in the ethical principles conflict,” (Behnke, 2005). In the context of client danger to

self, therapists are faced with an ethical dilemma that they must attempt to navigate using

best practice procedures delineated in the APA’s Ethical Principles of Psychologists and

Code of Conduct (APA, 2017). The most central ethical dilemma related to preserving

client safety is the relative weighing of the general principle of Beneficence and

Nonmaleficence, and the general principle of Respect for People’s Rights and Dignity.

As described above, the general principle of Beneficence and Nonmaleficence calls on

psychologists to protect the welfare of their clients, while the general principle of Respect

for People’s Rights and Dignity admonishes psychologists to “respect the rights…of

individuals to…self-determination,” (APA, 2017, p. 4). When it is apparent that a

client’s life may be in immediate danger, the psychologist must take appropriate and

proactive measures to mitigate this risk, through standard procedures such as safety

planning, consultation with colleagues and supervisors, welfare checks, and voluntary or

involuntary hospitalization. Such interventions, however, may be in conflict with the

patient’s desires. For example, a patient may object to safety planning procedures or

voluntary hospitalization, and the clinician’s pursuit of an intervention designed to

safeguard the patient’s welfare may impinge on their autonomy.

Another type of conflict may arise between an ethical principle (Beneficence and

Nonmaleficence), and another principle (Respect for People’s Rights and Dignity) and

the law. The United States Constitution alludes to the right to privacy in the 4

Amendment, which identifies “the right of the people to be secure in their persons,

houses, papers, and effects, against unreasonable search and seizures.” The California

Constitution explicitly gives each citizen an “inalienable” right to pursue and obtain

privacy. In psychology, the general principle of Respect for People’s Rights and Dignity

requires psychologists to “respect the rights…of individuals to privacy (and)

confidentiality…” (APA, 2017, p. 4). In other words, clients are afforded the rights to

privacy and confidentiality under the ethics code, as well as national and statewide law.

However, many suicide prevention measures necessitate a violation of privacy or a

breach of confidentiality. For example, a decision to involuntarily hospitalize a suicidal

client or call the police to perform a welfare check in accordance with the principle of

Beneficence and Nonmaleficence may also represent a subversion of Respect for Peoples'

Rights and Dignity, and may carry legal considerations.

Barriers to In-person Suicide Risk Assessment and Intervention

Given the trends in suicide rates and the clinician’s ethical and legal

responsibilities to the client, accurate and thorough suicide risk assessment has become

all the more necessary to protecting vulnerable clients and providing appropriate care.

The current norm in risk assessment is that it is conducted using information given by the

client during therapy, as well as previous records or reports from others, if available or

authorized by the client. However, this method has been shown to have barriers and

confounds that decrease the accuracy of the assessment, and the effectiveness of

subsequent intervention, which, in turn, can adversely impact the client's health and/or

the therapeutic alliance (Brown, Jones, Betts, & Wu, 2003).

For example, a common assumption across all theoretical orientations is that

clients disclose information related to their distress with their therapist. However, some

researchers have demonstrated that individuals may be resistant to disclosing negative

symptoms and behaviors to their therapist (Bauman & Hill, 2015; Hook & Andrews,

2005). Farber, Blanchard, & Love (2019) found that psychotherapy clients tended to not

only conceal distress levels and symptom severity from their therapists, but that an

alarmingly high percentage lied about their suicidal thoughts. Apter, Horesh, Gothelf,

Graffi, & Lepkifker (2001) found that suicide behavior severity was a major negative

factor in participants' willingness to disclose their experiences to their clinicians; the

more severe the behavior, the less likely it was disclosed. Given that interpersonal

isolation is a risk factor for suicide, client levels of disclosure become even more crucial

in the context of suicide prevention; nondisclosure of suicidal ideation by clients may

reinforce the feelings of isolation and lead to more severe suicide behaviors (Orf, 2014).

The quality of the therapeutic alliance is among the most robust predictors of

client disclosure (Orf, 2014). It has been demonstrated that strong therapeutic alliance

leads to increased client disclosure (Hall & Farber, 2001). Conversely, the results of

another study indicated that clients who reported having held a clinically relevant secret

from their therapist rated their therapeutic alliance with their therapist as lower than

clients who made such disclosures (Kelley & Yuan, 2009). Shea (2002) demonstrated

that the way clinicians probe for suicidal ideation and behavior may impact clients'

willingness to disclose, while Dew, Morgan, Dowell, McLeod, Bushnell, & Collings

(2007) and Farber et al. (2019) found that fears of certain practical outcomes (e.g.,

hospitalization, medication, job impact), clinician negative judgment, and facing their

distress "head on" are additional barriers to client disclosure. More specifically, Farber et

al. (2019) found that clients were more inclined to make disclosures regarding suicidality

if their therapists provided information and assurances regarding the consequences of the

disclosure, enhancing their sense of predictability and the therapist’s transparency.

Cultural and social factors also may contribute to client non-disclosure. Social

stigma against suicidal individuals discourages disclosure (Keller, McNeill, Honea, &

Miller, 2019), and Shea (2002) proposes that cultural values may discourage disclosure of

suicidal ideation or behavior, given that suicidality is seen in some cultures as being

sinful, taboo, or a sign of weakness.

Other hurdles are present during the in-person risk assessment process. Even

when disclosed, information provided by the client can often be ambiguous, and it may

be difficult to identify the appropriate suicide risk level. Accurate risk assessment is

contingent upon multiple factors, such as clinician competency, and the ability to discern

level of intent based on information provided by the client (Harrison, Stritzke, Fay, &

Hudaib, 2018), as well as varying psychometric properties of any formal assessment

measures used in the process (Chan, Bhatti, Meader, Stockton, Evans, O’Connor, &

Kendall, 2016).

There are also barriers to effective in-person intervention with a patient

determined to be at risk for suicide. For example, researchers have demonstrated that a

psychologist's response to a given safety risk situation is often heavily influenced by

factors such as fear of losing their client to suicide, or, conversely, a fear misusing

clinical resources or damaging rapport by depriving a client of their rights (Bryan &

Rudd, 2006). Furthermore, Thelen, Rodriguez, & Sprengelmeyer (1994) found that, when

navigating issues related to the breach of confidentiality (as sometimes is necessary to

safeguard a suicidal client), psychologists often reference their own “personal code”

when making these decisions. This self-reference standard may be partly responsible for

differences between psychologists in how they weigh the importance of confidentiality,

their beliefs about the risks and benefits of informing clients of the limits of

confidentiality, and their actual decisions to breach confidentiality. However, this study

also found that, despite these differences, most psychologists did not significantly differ

in their actual knowledge of the relevant ethical principles.

Many of the factors that influence client disclosure of suicidality, accurate risk

assessment, and effective intervention outlined above are specific to face-to-face

psychotherapeutic environments. However, despite efforts to consider these factors and

refine in-person risk assessment and management, an alarmingly high number of clients

attempt suicide, even after explicit denial of any suicidal ideation during a risk

assessment (Busch, Fawcett, & Jacobs, 2003). The grave statistics regarding suicide

attempts and completions in the U.S., the mental health professionals’ ethical, legal, and

clinical responsibilities to prevent such tragedies, the barriers to in-person assessment and

management of risk, and the recent research reports that suicide risk assessment and

intervention may be enhanced when supplemented with online resources provide support

for the recommendation that researchers and clinicians explore the use of patients’ digital

information to enhance care. The next two sections below outline the information

potentially available on SM regarding patients’ risk status, and the specific ethical

implications of clinicians’ use of that information to assess and manage suicidal patients.

Clients’ Expressions of Suicidality on Social Media

Psychology's increasing presence on the internet and SM undoubtedly represents

a positive step toward blending the in-person and digital social worlds to make effective

mental health information and services more flexible and deliverable for therapists, safer

and more accessible for clients, and overall more adapted to this digital age. Still, in

addressing the association between SM and suicidality disclosure, there are gaps in both

the research and the clinical implications of this relationship. However, given that SM is

a primary way that individuals share and discuss their experiences, researchers have

begun to further investigate the role of SM in individuals' willingness to disclose that

they are suicidal, as well as how they make the decision to disclose.

To this end, the expression and detection of suicidal ideation and behavior on SM

has evolved into a leading area of research in suicide prevention (Vioulés, Moulahi, &

Bringay, 2017). Numerous studies have demonstrated that, in the face of social stigma

related to the disclosure of mental health struggles, even in a professional environment,

people are increasingly using online platforms, like SM, to discuss their struggles (De

Choudhury, Gamon, Counts, & Horvitz, 2013; Moreno, Jelenchick, Egan, Cox, Young,

Gannon, & Becker, 2011). De Choudery et al. (2013) also found that the current

knowledge surrounding the indicators and detection of depression, a symptom often

associated with suicidal ideation and behavior, also translate to online environments. For

example, depressed individuals use SM later at night, use more first-person pronouns,

and interact less with other people online (De Choudery et al., 2013). There have also

been many social computing and linguistic studies that have attempted to examine

language patterns in the online profiles of individuals who are suicidal (Gunn & Lester,

2012; De Choudery et al., 2013; De Choudery, Kiciman, Dredze, Coppersmith, &

Kumar, 2016). Furthermore, by using artificial intelligence in the form of machine

learning and natural language processing, researchers have attempted to draw on these

findings to describe and construct algorithmic models that can estimate level of suicide

risk in individuals based on their SM language, and even identify individuals who may

become at risk in the future (Coppersmith, Leary, Crutchley, & Fine, 2018).

One theory offered to explain why SM may facilitate disclosure of suicidality is

rooted in traditional psychoanalytic theory. A central tenet of psychoanalysis is that the

therapist should act as a "blank slate" -- that is, the therapist should attempt to suppress

any facial expressions or body language in order to allow their clients to express

themselves without fear of reaction or judgment from the therapist. In his classic article

on the "Online Disinhibition Effect," Suler (2004) conceptualizes the blank slate as a

form of "invisibility," which is one of the six factors that he describes as facilitating

online communicative patterns. In other words, the social dynamics of online

environments and the lack of immediate physical cues that indicate that the

communicator is “visible” and another is receiving the information enhances individuals’

tendencies to share their innermost experiences.

Suler delineates other factors in addition to invisibility that lead to the

disinhibition of online disclosures. "Minimization of authority" refers to the erosion of

indicators of authority in online environments, which, again, allows people to express

themselves without being intimidated by authority that might otherwise be present in

face-to-face interactions.

Suler also states that the online experience can facilitate a feeling of escapism,

since the "normal" rules of social interactions either do not apply or are significantly

altered in online environments. Instead of seeing online interactions as an extension of

face-to-face interactions, people can compartmentalize these different social domains,

which can lead to increased disinhibition online; he labels this factor as "dissociative

imagination."

"Dissociative anonymity" refers to the safety people feel to express themselves

when they are able to remain anonymous on the internet. Further, the term

"asynchronicity" is used to describe the fact that online interactions usually do not take

place in real time, thus allowing people to post content without immediately seeing or

feeling others' reactions to their posts. Finally, other individuals on the internet can

become part of our own "psychic world"; in the absence of face-to-face cues, individuals

read others' online content in their own heads, with their own voices. One's personal

needs, desires, and biases influence how they experience others' online content, which

can make others more familiar and comfortable to interact and share with; Suler (2004)

labeled this factor "solipsistic introjection."

Suler's Online Disinhibition Effect (2004) provides some theoretical insight into

why the social dynamics of online environments and SM may ease peoples' disclosure of

suicidality. According to Suler (2004), these six factors refer to distinct characteristics of

online communication that lead to behavioral disinhibition and a decreased consideration

of social ramifications of personal disclosure. Though some of these factors may be more

relevant than others to the understanding of SM disclosures, taken together, they can be

conceptualized as a collection of social dynamics unique to the online environment that

loosen social conventions or constraints, and, thus, allow people to express themselves

more freely. Considering the level of social stigma related to the expression of suicidality

and the seeking out of mental health resources, as well as the role of stigma as a

significant cultural barrier to suicide prevention (Keller et al., 2019), these factors make

apparent the function that online environments may play in individuals' expression of

suicidality on SM.

Ethical Implications of Digital Suicide Risk Assessment and Intervention for

Psychologists

Researchers have begun to examine therapists' engagement in various online

behaviors, both personally and related to their work with clients in crisis and non-crisis

situations, as well as the clinical and ethical implications of such behaviors (Kolmes &

Taube, 2014; Tunick, Mednick, & Conroy, 2011; Zur & Zur, 2011; Lehavot, Barnett, &

Power, 2010;). However, there are, to date, no reports of research specifically designed

to examine the use of client digital information to inform suicide risk-related assessment

and intervention. Furthermore, while other mental health professional organizations (e.g.,

NASW and ACA) have included in their codes of ethics specific standards relevant to

their digital behaviors, the Ethical Principles of Psychologists and Code of Conduct

(APA, 2017) has not yet been modified to include such standards to guide psychologists’

digital conduct. As such, psychologists must rely on APA’s more general aspirational

ethical principles and guidelines, as well as ethical standards presented by other mental

health professions to inform such conduct. The next section will detail and discuss the

implications of the following for digital suicide risk assessment and intervention: (1)

APA general ethical principles of Beneficence and Nonmaleficence, Fidelity and

Responsibility, Integrity, Justice, and Respect for People’s Rights and Dignity (APA,

2017); (2) APA Guidelines for the Practice of Telepsychology (APA, 2013); (3) specific

relevant standards from the ethics codes of the National Association of Social Workers

(NASW, 2017) and the American Counseling Association (ACA, 2014), and 4)

aspirational guidelines from the American Psychiatric Association (ApA, 2016) and

forensic psychologists.

APA General Ethical Principles

As discussed above regarding in-person suicide assessment and intervention,

psychologists’ decisions regarding engagement in digital suicide risk assessment and/or

intervention may be similarly guided by the APA’s aspirational ethical principles of

Beneficence and Nonmaleficence, Fidelity and Responsibility, Integrity, Justice, and

Respect for People’s Rights and Dignity. However, there are some additional

implications of the general principles raised by accessing and using clients’ SM to assess

and intervene in the context of suicide risk.

First, with regard to the general principle of Beneficence and Nonmaleficence, the

potential of acquiring additional information by accessing clients’ SM that may inform

the clinician’s assessment and management of suicide risk certainly upholds the

professional’s ethical responsibility to safeguard the welfare of the client. Second, the

mandates to establish and maintain relationships of trust with clients, to promote

accuracy, honesty, and truthfulness in the practice of psychology, and to ensure client

self-determination that are captured by the ethical principles of Fidelity and

Responsibility, Integrity, and Respect for People’s Rights and Dignity carry implications

for the importance of fully informing the client regarding the practice of accessing SM in

the context of suicide risk. Kaslow, Patterson, & Gottlieb (2011) explored some special

considerations for the informed consent process in the context of psychologists'

professional use of digital resources. Their discussion highlighted the importance of

explicitly addressing the therapist’s digital practices during the informed consent process

with clients. The authors noted, however, the inclusion of these potential digital

boundary crossings in the informed consent process does not preclude such crossings

from being professionally unsound and potentially damaging to the therapeutic alliance

for individual clients. Therefore, including issues related to psychologists' digital

presence, especially in the context of safety risk, should be approached proactively and

intentionally, with the overall goal of doing everything possible to maintain the trust and

respect the rights of each individual client, rather than with the goal of meeting minimum

professional requirements. To this end, an informed consent document that thoroughly

addresses issues related to client SM access would include, but is not limited to, the

professional rationale for conducting a client SM search, specifying what types of

situations may indicate a SM-informed risk assessment or digital welfare check, what SM

platforms and features of those platforms the therapist would attempt to use, whether or

not the therapist uses a personal or professional SM profile to conduct the check, the

scope of the online access, how the therapist would determine when they have obtained

sufficient information to end the access, how the information obtained may be acted

upon, and how the client may be informed of the access process and outcome. Clients

also must be made fully aware of the risks and benefits of an appropriately conducted

SM-informed risk assessment or digital welfare check. Finally, the client must have the

right to deny the psychologist access to their SM page, even if there is a safety concern.

Further, the general principle of Justice in the context of a SM-informed risk

assessment or digital welfare checks becomes relevant in two ways. First, it is not

possible for a clinician to filter a client's SM page only for information relevant to the

purpose of the check. Therefore, it is virtually guaranteed that the clinician will encounter

information about their client that the client did not disclose in person and is irrelevant to

client safety. Seeing, interacting with, or using this information may not only lead to a

violation of client privacy, but also the discovery of elements of the client's social life or

personal identity that may lead to the development of new biases. For example, research

suggests that psychotherapy has become increasingly "value-laden," which can lead to

therapists' social and political views (and their congruence or incongruence with that of

their client) influencing diagnosis, intervention, and treatment (Woolfolk, 1998).

Therefore, it is important for any clinician conducting a SM-informed risk assessment or

a digital welfare check to maintain awareness of and address any biases or

countertransference reactions that may arise during or after the check.

The principle of Justice also requires psychologists to practice in accordance with

their level of competency and limitations of their expertise (APA, 2017). Given that SM

is a relatively new and ever-evolving social environment, there may be a learning curve

for some therapists in how to access and navigate these sites. The digital realm may also

consist of abbreviations, acronyms, slang terms, and other patterns of communication that

may be more difficult to understand and derive relevant clinical information from,

compared to traditional therapeutic interactions. In order to mitigate this, psychologists

who wish to conduct SM-informed risk assessments or digital welfare checks need to

have an adequate understanding of how online and in-person communication may differ,

and should strive to maintain a certain level of digital literacy and skill.

Finally, the general principle of Respect for People’s Rights and Dignity carries

unique implications for the protection of the client’s privacy and confidentiality in the

context of accessing client SM information online. SM-informed risk assessment and

digital welfare checks each potentially provide the clinician with crucial information that

is less likely to involve the release of confidential information to others (e.g., the police

or family members). There is, however, also the consideration noted above that the

clinician, while accessing a client’s SM for information relevant to risk assessment and/or

intervention, may come across other information about the client that the client has not

shared in session. In addition to dealing with any potential countertransferential reactions

or triggered biases, the clinician must also be clear with the client about the possibility of

accessing such information, and whether and how the clinician will bring the discovery

into session for future discussion.

It is also important to note that the general principle of Respect for Peoples'

Rights and Dignity stipulates that "special safeguards may be necessary to protect the

rights and welfare of persons….whose vulnerabilities impair autonomous decision

making” (APA, 2017, p. 5). Suicidal patients are often seriously depressed, psychotic,

and/or under the influence of substances and, arguably, are suffering from diminished

abilities to make rational decisions. The clinician must determine the level of suicide

risk, including the client’s level of impulsivity and/or diminished cognitive functioning.

And, in addition to the technical and interpersonal skills required to discern suicide risk

level in clients, risk situations also involve choosing or not choosing to take protective

action based on that level of risk; they must determine whether additional safeguards that

require an imposition on the client’s self-determination and/or a breach of confidentiality

or violation of privacy is necessary for a client's protection. Increasing the amount of

risk-relevant information through accessing the client’s SM information potentially can

improve risk assessment procedures. In turn, more accurate risk assessment can enhance

subsequent risk-related treatment decisions, and the decisions are more likely to be

centered around objective data. Therefore, the decision will be less likely to impose

unnecessarily on the client’s self-determination regarding intervention options.

APA Guidelines for the Practice of Telepsychology

The APA’s Guidelines for the Practice of Telepsychology (APA, 2013) contain

guidance that can reasonably be applied to the potential acquisition and use of client SM

to mitigate suicide risk. The Guidelines state that psychologists should strive to maintain

ethical and professional standards of care while providing teletherapy (APA, 2013). This

would include determining the appropriateness or utility of teletherapy with a given

client, continuously evaluating the safety and efficacy of teletherapy with that client, and

considering relevant demographic and cultural factors that may impact the efficacy of

teletherapy. The APA also states that informed consent must specifically address unique

concerns related to the provision of teletherapy, and abide by applicable national or

statewide laws. This would include explicitly addressing with the client the risks and

benefits of using teletherapy. These guidelines can be informative for the identification of

ethical concerns and the development of future ethical standards related to expanding

psychological services in the digital sphere. For example, in applying the teletherapy

guidelines to the potential use of client SM to preserve safety, it would need to be

clinically justified to do so, based on factors like client demographics, level of risk, and

the nature of the specific situation.

Ethical Standards of Other Mental Health Professions

The National Association of Social Workers (NASW) has published a handbook

titled "Technology in Social Work Practice," which provides standards related to a wide

range of topics relevant to the professional and ethical practice of Social Work in the

digital sphere (NASW, 2017). Some of these standards may be of particular relevance

when they are applied to SM-informed risk assessment or digital welfare checks. For

example, Standard 2.10 specifically states that social workers should provide their clients

with a social media policy in order to maintain clear boundaries and protect private

information. Clinicians uphold this standard by clearly outlining the difference between

clinical and personal usage of social media, and the different rules and boundaries that

apply to each. Standard 2.05 states that social workers should actively assess for how

their clients use social media, meaning that therapists who wish to incorporate SM-

informed risk assessment or digital welfare checks into their practice should attempt to

identify the clinical utility of their client's SM page, ideally before any check is

conducted. Standard 3.06 requires social workers to take measures to ensure the

credibility and accuracy of any information obtained online. This standard then implies

that therapists should discuss with and confirm information retrieved from a clients’ SM

page with the client. The NASW also specifically addresses the gathering of client

information online using search engines, stating in Standard 3.09 that using online

sources to gather information on a client should only be done for "compelling

professional reasons," and with the client's consent (NASW, 2017).

The American Counseling Association also added a section to their ethics code

(ACA, 2014) that outlines specific ethical standards related to the practice of counseling

in the digital sphere. These standards address multiple aspects of counselors' online

presence, both professionally and personally. For example, standard H.1. (p. 17)

specifically requires counselors "who engage in the use of technology and/or social

media [to] develop knowledge and skills regarding related technical, ethical, and legal

considerations." Standard H.2. (p. 17) discusses special considerations for informed

consent related to the digital practice of counseling, explicitly stating that clients reserve

the right to choose whether technology is incorporated into their counseling. More

specific to the mitigation of risk through SM, standard H.6.b. requires counselors to

discuss with their clients the benefits, limitations, and boundaries of their SM use (p. 18),

while standard H.6.c. requires counselors to respect the online privacy of their clients,

except in situations where the client has given consent to review their SM profiles.

The American Psychiatric Association (ApA) also provided similar guidelines in

2016. For example, the ApA's Ethics Committee recommends that online searches of

clients only be conducted after obtaining the client's informed consent, "except in

emergencies" (Dike, Candilis, Kocsis, Sidhu, & Recupero, 2019). The committee also has

called upon psychiatrists to maintain awareness of any personal motivations they may

have in conducting a client search. Also recommended is the sensitive handling of any

private information gathered during an online search of a client, as well as careful

consideration of any potential influence that a client search may have on rapport.

Of particular relevance to SM-informed risk assessment and digital welfare

checks is the American Psychiatric Association's recommendation that information

gathered online, when interpreted cautiously, may be informative in forensic situations.

Indeed, forensic psychologists have also examined numerous ethical implications of

utilizing SM data to inform treatment decisions. There appears to be a consensus among

forensic psychologists that gathering information on a client from an online source is

appropriate under certain conditions, and even a standard of practice (Griffith, 2018).

In summary, psychologists have yet to develop specific ethical standards related

to their general digital presence, and more specifically regarding using SM to augment

assessment and interventions with clients at risk for suicide. However, there is ethical

guidance available for psychologists to thoughtfully develop approaches to the

appropriate use of client SM that strike a balance between professional ethical and legal

responsibility to clients and clinical utility. There is potentially much to be gained from

suicide risk assessment and management using client SM.

Potential Benefits of Social Media-Informed Risk Assessment and Digital Welfare

Checks

The designation of suicide as a public health crisis has substantially affected how

suicide is approached by researchers and clinicians. Specifically, primary prevention has

become a main focus in suicide prevention. Public health officials, clinicians, and

legislators have adopted a more proactive, population-focused approach to addressing

suicide and suicide risk through assessing both proximal and distal risk factors. (CDC,

2019). Part of this ideological shift involves an increased effort by professionals to

identify and mitigate risk early on in at-risk individuals. Expanding the way in which

relevant information for at-risk individuals is obtained and used represents a potential

next step in achieving this goal. In an era where digital platforms are at the forefront of

human interaction and expression, the utilization of client information obtained by

clinicians via SM, when guided by ethical, legal, and clinical standards of care, may lead

to improvement in how mental health professionals identify suicide risk and undertake

risk-related treatment interventions. Thus, the task for mental health researchers and

clinicians is to identify ways that SM can be ethically drawn upon to inform clinical

decisions in situations where the client’s safety may be at risk. Specifically, because of

the unique role that SM may play in freeing people up to disclose their innermost

struggles, the clinician may be remiss not to consider the potentially valuable, and

conventionally untapped, information available for accurate suicide risk assessment and

effective prevention. Two possible novel methods of assessment and intervention

involving SM include: (1) a "SM-informed risk assessment," where clinicians use

information on clients' SM profiles to inform risk level and (2) a "digital welfare check,"

whereby clinicians gain access to and use information found on an at-risk individuals' SM

page in order to determine whether additional safety interventions are clinically indicated.

Social Media-Informed Risk Assessment

Identification of suicide risk is a complex process that requires professional

judgment, and is subject to error in both the identification of the risk level itself, and

subsequent clinical decisions based on that risk. For example, current research suggests

that clinicians tend to err on the side of caution when conducting risk assessments

(Bongar & Sullivan, 2013), which may lead to inaccurate appraisals of risk and

unnecessary hospitalizations. Given that suicide prevention is a cornerstone of mental

health care, psychologists should always be striving to refine the risk assessment process

by considering alternative or supplemental approaches to risk assessment. The use of SM

as an additional resource of information related to suicide risk may represent such an

approach. If a client consents, and understands what kind of information the clinician is

seeking and accessing, a focused review of the client’s SM profile may reveal

information that can be helpful in making an accurate determination of risk level, such as

language or media indicative of a suicide plan or intent. Conversely, a SM-informed risk

assessment may provide evidence of strong social support for the client, a protective

factor against suicide.

If conducted in a manner that is aligned with ethical principles and applicable

legal statutes, there may be some potential benefits to psychologists accessing clients' SM

profiles. Given the evidence that suggests that some clients do attempt suicide, despite

explicit denial of suicidal ideation during a risk assessment, there is a need for refining,

modifying, or potentially expanding risk assessment procedures. This is the first potential

benefit of accessing a client’s SM; with the addition of information from SM may come

an increase in the accuracy of risk assessments and, thus, the determination of

interventions that are appropriate for the situation, minimizing risk to both the client and

the clinician. For example, information derived from a SM-informed risk assessment

conducted on a client with an ambiguous level of risk may reveal that they have access to

lethal means, or that they have articulated a suicide plan online. Conversely, the SM

information may reveal strong social support for the client or the client’s frequent

engagement in pleasant activities.

Digital Welfare Checks

In an effort to make suicide-preventative treatment decisions that are both

clinically indicated and ethically justified, a digital welfare check is another specific type

of SM access that may also be beneficial in situations where the client has already been

determined to be at high-risk, and there is legitimate concern for the immediate safety of

that client. A "digital welfare check" is conducted by clinicians who gain access to and

use information found on an at-risk individuals' SM page in order to determine whether

additional safety interventions are clinically indicated. A digital welfare check resembles

an in-person welfare check, which is an established protective measure available to

psychologists when there is sufficient concern for the client’s immediate safety, but the

client cannot be reached. During a welfare check, the psychologist informs authorities

(e.g., the police or emergency response team) of their concern for their client’s safety,

and provides identifiable information in order for the authorities to physically check in on

the client, typically at their residence. The authorities then respond to the client’s home to

ensure that they are safe, and report back to the therapist.

Though the goal of a digital welfare check closely resembles that of a traditional

welfare check—to gather information that informs risk level and ensure the safety of the

individual—a key part of an in-person welfare check is that it necessitates a breach of

confidentiality. If a clinician contacts the authorities and asks for a welfare check to be

conducted on one of their clients, the clinician is required to provide identifying

information on their client, their physical location, and the reason for requesting the

welfare check. A digital welfare check represents an intermediate step in ensuring client

safety by obtaining potentially relevant information, without a breach of confidentiality to

another person. As previously discussed, a breach of confidentiality to ensure client

safety creates a tension between the ethical principles of Beneficence and

Nonmaleficence, and Respect for Peoples' Rights and Dignity, that may disrupt the

therapeutic alliance and subject the clinician to ethical and professional scrutiny. For

example, if a high-risk client does not show up for an appointed therapy session and

cannot be reached by the therapist on the phone, or via text or email (and there is prior

consent to having their SM profile checked if there is a safety concern), a digital welfare

check may reveal an innocuous reason for the no-show, such as a spontaneous vacation

or another medical appointment. In this case, the clinician would be able to obtain

relevant information regarding the client that indicates that no further action would be

warranted, and the information was obtained without any breach of confidentiality, and

under conditions that were previously agreed upon by the clinician and client.

Conversely, if a client does not show up for a therapy session and cannot be reached, and

the psychologist discovers disclosures or other information suggesting suicidal intent or

behavior during the digital welfare check, further protective measures would then be

clinically indicated, which would justify the breach of confidentiality inherent in a

traditional safety check.

It is also worth noting that involuntary hospitalization can damage rapport and

leave clients with a decreased sense of control over their lives (Katsakou & Priebe, 2007),

and can actually have deleterious effects on the emotional and cognitive functioning of

people with severe mental illness (Rüsch, Müller, Lay, Corrigan, Zahn, Schönenberger,

Bleiker, Lengler, Blank, & Rössler, 2013). Given these findings, psychologists should be

striving to reserve psychiatric hospitalization for only the most urgent situations, and a

digital welfare check may help clinicians in determining whether involuntary

hospitalization is necessary for a client's safety. Finally, there are documented incidents

of officer-related homicides occurring during welfare checks, especially involving

individuals who are severely mentally ill or are a danger to self or others (CNN, 2019). A

digital welfare check may help in avoiding such tragic outcomes.

Research Regarding Therapist Access and Use of Client Social Media Information

Therapist access and use of client SM information represent a potential new

useful approach to suicide risk-assessment and intervention that can promote the

clinician’s ethical duty to protect clients and sustain the patient’s privacy, confidentiality,

self-determination, and trust. There is, unfortunately, a paucity of research literature

regarding clinicians’ access and use of their clients' SM profiles specifically for the

assessment and prevention of suicide. However, several researchers have examined the

frequencies with which clinicians conduct client searches online for other reasons and the

outcomes of those searches. Furthermore, some researchers have attempted to identify

clinician characteristics that are associated with therapist engagement in these online

behaviors.

Online Client Searches: Frequencies, Reasons, and Disclosures to Clients

One recent survey study of 130 psychologists reported that 41.2% of therapist

participants engaged in adult patient-targeted online searches at least “rarely” (Wu &

Sonne, 2019). Similarly, Eichenberg & Herzberg (2016) reported that nearly 40% of the

207 therapists they surveyed acknowledged searching online for information about their

clients, and two-thirds of those clinicians indicated that such conduct could benefit

treatment.

Kolmes and Taube (2014) found that 48% of their 227 mental health professionals

or professionals in training reported intentionally seeking information online about

current clients in a noncrisis situation without the client’s awareness; 81% did so to find

information related to treatment or verification of information shared in the therapy

session. The authors also reported that all searches among the 8% of participants who

searched online for client information during a crisis were related to client safety or

location. Of those respondents, more than half (53%) indicated that they found the

information found was useful in resolving the crisis.

Ginory, Sabatier, & Eth (2012) surveyed 187 psychiatry residents recruited from

the American Psychiatric Association and found that 18% acknowledged accessing client

profiles on Facebook. Among the reasons given for the searches were checking on a

client who had missed sessions and looking for evidence of suicidal ideation. And,

Lehavot et al. (2010) found that 27% of the psychologists and therapists in training had

searched the internet for information about their clients. Reporting a much higher

percentage, DiLillo & Gale (2010) reported that 89% of the U.S. and Canadian doctoral

students they surveyed had sought information about clients at least once in the last year.

Another early survey study of 246 psychologists and psychologists-in-training

working with younger clients found that 32% of respondents reported accessing a client's

online profile (Tunick et al., 2011). The authors also found that the respondents who did

endorse conducting client online searches did so for various reasons. Notably, the largest

proportion of respondents who endorsed searching for clients online did so out of

therapeutic concern (41%). Furthermore, some respondents indicated that they indeed

discovered information indicative of suicidal ideation on their clients' online profiles.

Conversely, of the respondents who indicated that they have never engaged in online

client searches, 29% reported that there has never been a need for them to do so, and 63%

stated that they felt online client searches fell outside of appropriate therapeutic

boundaries.

Tunick et al. (2011) also found that there were differences among respondents

who endorsed conducting online client searches regarding how they navigated the

situation with their clients. Approximately, 20% of these respondents conducted the

search without explicit permission from their client, but did inform them that a search

was conducted; 40% asked permission from their client to conduct the search prior to

doing so; 22% reported that their decision to obtain client permission before conducting

the search depended on the situation; and 18% did not ask for permission, nor inform

their client that a search was conducted.

Though Tunick et al. (2011) did not specifically report how many respondents

discovered suicidal content on their clients' pages and whether that content was

discovered with or without client permission to conduct the search, the authors did find

that suicidal content was indeed among the concerning content discovered by some of

these respondents. Furthermore, the authors found a significant correlation between the

discovery of concerning online content, and the addressing of those concerns in face-to-

face therapy sessions (Tunick et al., 2011). Therefore, like the respondents in the Kolmes

& Taube (2014) study, many of those therapists who did discover suicidal content on

their clients’ SM found the information relevant and helpful in their efforts to safeguard

the clients’ welfare.

Therapist Characteristics Affecting Willingness to Conduct Online Client Searches

The studies cited above demonstrate heterogeneity among clinicians regarding

their decisions to conduct online client searches, their reasons for doing so, how they

used the information, and how they approached the issue with their clients. Some

preliminary research has examined whether certain clinician characteristics, like therapist

age, gender, and theoretical orientation, may explain some of that variance. However, to

date, there is no research that has examined the degree to which therapists rely on each of

the five APA general principles to guide decisions related to whether or not to conduct an

online search; however, there is significant literature that suggests that psychologists'

relative allegiance to each general ethical principle may too be a significant predictor of

certain online behaviors, especially in the context of client safety risk.

Therapist Age

A German study found no significant effect of therapist age for the prediction of

those who did vs. did not conduct online client searches (Eichenberg & Herzberg, 2016).

Similarly, Kolmes & Taube (2014) found no significant age effects in their survey of

practicing clinicians and clinicians in training. In contrast, Jent, Eaton, Merrick,

Englebert, Dandes, Chapman, & Hershorin (2011) surveyed behavioral health faculty and

trainees regarding their accessing and use of client SM accounts and found that only

trainees endorsed conducting an online client search. The authors posited that their result

was likely due to the trainees’ status as "digital natives," defined as younger individuals

"whose online presence began primarily as a social one," and who were "born during or

after the introduction of digital technology," (Jent, et al., 2011). The authors argued that a

digital native is more likely to have been exposed to the complex culture and

communicative patterns of SM sites, and this increased exposure could lead to more

experiences in which they see a blending or overlap of peoples' online and offline selves.

Therefore, digital native clinicians may be more likely to view SM as an accessible and

valid indicator of their clients' current mental health and psychosocial functioning. The

researchers’ reasoning may explain the higher frequency of engagement in accessing

client online information reported by DiLillo & Gale (2011) who surveyed a large group

of doctoral students. Though the actual dynamics of online communication may differ

from those found in face-to-face interactions (Suler, 2004), the notion shared among

digital natives that SM can act as an available and valid resource for relevant clinical

information is at least partially supported by numerous studies that suggest that peoples'

online profiles represent an extension of their internal and social selves, rather than a

compartmentalized or distinct version of either (Moreno et al., 2011; Gunn & Lester,

2012; De Choudhury et al., 2013; Coppersmith & Kumar, 2016; Coppersmith et al.,

2018).

Therapist Gender

Survey studies by Eichenberg & Herzberg (2016) and Kolmes & Taube (2014)

failed to find a significant effect of therapist gender on the frequency of searches for

online client information. However, Wu and Sonne (2019) found that male therapists

were likely to endorse less engagement in patient-targeted searches than did female

therapists.

Therapist Theoretical Orientation

The effects of theoretical orientation on clinician online behaviors has also been

examined; results have varied. For example, Wu & Sonne (2019) found no significant

relationship between theoretical orientation and actual engagement in online client

searches. However, Kolmes & Taube (2014) found that their therapist respondents with a

CBT theoretical orientation were significantly less likely to intentionally search for client

information on the internet than were respondents who self-identified as psychodynamic

or integrative. Interestingly, although Eichenberg & Herzberg (2016) did not find that

the therapists’ theoretical orientation predicted actual behavior, they did report that

therapists trained in psychodynamic or psychoanalytic therapy significantly more often

perceived the behavior as unjustifiable in all situations.

Suler (2004) provides a rationale for the prediction that psychoanalytic therapists

would perceive online client searches as unjustifiable and be less likely to engage in the

conduct. Specifically, Suler states that online environments may facilitate what Ziv-

Beiman (2013) describes as an "interpersonal void," similar to that which Freud argued

should be characteristic of the analytic space, in order to facilitate the emergence of

unconscious conflicts and transferential projections (Strachey & Freud, 1957). In

applying these arguments and concepts to how we currently approach psychological

practice in the digital sphere, it may be that psychoanalytic/psychodynamic therapists'

reluctance to self-disclose in in-person psychotherapy would extend to online behaviors

that they might regard as contaminating the therapeutic relationship. In other words,

psychoanalytic/psychodynamic therapists may be more ethically and interpersonally

conservative than therapists of other orientations in how they conceptualize and navigate

boundary issues related to clinical practice in the digital sphere. Thus, they may be less

likely to use SM checks as a safety measure for at-risk clients (though they would

conceivably avoid doing so based more on clinical reasons than ethical ones).

Therapist Reliance on General Ethical Principles

As previously discussed, the relative weighing of general ethical principles is

inherent to navigating ethical dilemmas, like those inherent in suicide risk assessment and

management. Research is sparse regarding trends in if or how American psychologists

subjectively rank the general ethical principles, and the level to which those ethical

rankings influence ethical decision-making. However, ranking of ethical principles is not

only addressed in Canadian research; it is an instrumental part of their approach to

developing their current ethics code. The Canadian Psychological Association's (CPA)

approach to ethics is based on a consensus among Canadian psychologists that certain

ethical principles are more important than others, and should be more heavily weighed

during ethical decision-making (Sinclair, Poizner, Gilmour-Barrett, & Randall, 1987).

The CPA has responded to this "collective wisdom" not only by including ethical

principles and standards based on how Canadian psychologists navigate ethical

dilemmas, but also by embedding a rank of those principles into the Canadian Code of

Ethics for Psychologists to guide decision-making (CCEP; CPA, 2000). The CCEP,

which is widely regarded as one of the best and most influential ethics codes in the world

(Hadjistavropoulos, 2011), presents the following rank order of their ethical principles (in

descending order): Respect for the Dignity of Persons, Responsible Caring, Integrity in

Relationships, Responsibility to Society.

An important part of these rankings is that they are based directly on responses

from a sample of psychologists who indicated how they navigated certain situations

where ethics were of concern (Sinclair et al., 1987); therefore, at the time of its

publication, the ranking of the ethical principles were an accurate representation of

general trends found in Canadian psychologists' actual ethical attitudes and decisions.

Notably, research on the usefulness of a hierarchical ethics system remains limited,

though there is some level of theoretical and empirical support for this system (Williams,

Hadjistavropoulos, Malloy, Gagnon, Sharpe, & Fuchs-Lachelle, 2002). However, it is

still unclear whether this ethical system results in increased consistency of ethical

decision-making (Hadjistavropoulos, 2011), most likely because research indicates that

Canadian psychologists' ethical decision-making is guided by both the ranking itself, and

by contextual factors (Seitz & O'neill, 1996). Still, this approach to developing the CCEP

was rooted in the goal of increasing consistency in ethical decision-making, especially in

the case of ethical dilemmas (Hadjistavropoulos & Malloy, 2000).

The development of the APA ethics code followed a similar procedure to that of

the CCEP, in that it was developed using qualitative data on how American psychologists

commonly make decisions with ethical considerations. However, the APA has not yet

included a rank of its general principles. Therefore, in the absence of clear ethical

standards or a ranking of general principles, clinicians often make ethical decisions in

accordance with their own personal code (Thelen et al., 1994), which can be influenced

by factors like seeking pleasure and avoiding pain for oneself, perceptions of others'

values, potential consequences of a particular decision, and transrational factors like "gut-

feeling" (Hodgkinson, 1996).

Though the study was conducted using the 1992 version of the APA ethics code,

Canadian researchers Hadjistavropoulos & Malloy (1999) attempted to construct a

theoretically-based ranking of the APA's general ethical principles by applying

Hodgkinson's (1996) theoretical framework of morality, which aims to draw a distinction

between what is morally "good" and morally "right," and further distinguishes among

various "levels" of moral reasoning. The first level is preference, which essentially refers

to the deciding party's personal moral values. The next level is consensus; moral and

ethical decisions are evaluated and made based on whether the decision would reasonably

line up with the majority. The third level is consequence, which takes a pragmatic

approach to evaluating potential solutions to nomothetic problems, rather than individual

ones. For example, a decision may be made based on the fact that it would benefit the

field of psychology as a whole. The highest level of moral reasoning is principle, which

can be understood as the collectively shared, internal "compass" of morality that

encapsulates values and social conventions largely shared across peoples and cultures.

The authors also incorporated the concept of moral intensity (Jones, 1991) into

their rankings in an effort to identify different dimensions of a situation that people may

draw upon to make moral and ethical decisions. For example, Jones identifies magnitude

of consequence (the sum of the good or bad that would come from a particular decision),

probability of effect (the likelihood of a good or bad effect coming from a particular

decision), and temporal immediacy (the temporal urgency of the situation) as three of the

main factors that influence peoples' decision-making. Of note, these are the three

dimensions of his framework that are the most relevant in terms of clinicians' decisions

regarding preserving client safety/privacy. For example, magnitude of consequence is

important because a misstep in navigating client risk could result in the client dying by

suicide (or a complete rupture in rapport). Probability of effect is important because

ethical dilemmas require one to take the course of action that is most probable to have

"good" results for the client (though the clinician's and client's idea of what is “good”

may vary). Temporal immediacy is important because it captures the temporal urgency of

risk-related situations and the importance of assessing and resolving the issue quickly.

Based on these two moral frameworks, Hadjistavropoulos & Malloy (1999)

classified Respect for People's Rights and Dignity as the most important general

principle, followed by (in descending order of importance) Concern for Others' Welfare,

Competence, Integrity, Professional and Scientific Responsibility, and Social

Responsibility. Despite the differences between the APA ethics code and the CCEP, as

well as differences between general ethical principles found in each version of the APA

ethics code, these findings support the presence of a somewhat uniform ranking of

general ethical principles among Canadian and American psychologists. Furthermore,

since the old principle of Concern for Others' Welfare most closely resembles the current

general principle of Beneficence and Nonmaleficence, these findings highlight that the

two principles most commonly regarded as the most important are indeed the two ethical

principles involved in the primary ethical dilemma related to preservation of client safety.

These studies are representative of an approach taken by some in field of

psychology to identify the importance of each of the general ethical principles, in an

effort to provide a guide to streamlined ethical decision-making. Less is known, however,

about the extent to which reliance on each of the principles impacts ethical decision-

making. One study (Patel & Sonne, 2020) examined the relationship between licensed

clinicians' ranking of the APA general ethical principles, and their ability to recognize a

potential nonsexual multiple relationship with a current client presented in a vignette. The

authors asked participants to rank seven ethical principles from least important to most

important in the process of their ethical decision-making in general: Beneficence,

Nonmaleficence, Respecting Patient Rights and Dignity, Justice, Integrity, Individual

Responsibility, and Professional and Scientific Responsibility to Society. Though the

researchers found no relationship between participants' differential reliance on these

ethical principles and their ability to detect a potential nonsexual multiple relationship,

approximately one-third of the psychologists (32%) identified Nonmaleficence as the

ethical principle on which they had the greatest reliance, followed by (in descending

order): Integrity (18.2%), Beneficence (16.4%), Respecting Patient Rights and Dignity

(13.4%), Professional and Scientific Responsibility to Society (7.4%), Individual

Responsibility (5.9%), and Justice (1.1%; Patel & Sonne, 2019).

These findings, along with the findings from Hadjistavropoulos & Malloy (1999),

suggest that Beneficence and Nonmaleficence and Respect for Peoples' Rights and

Dignity (autonomy) are among the most important general ethical principles for both

Canadian and American psychologists in their clinical work. As previously discussed,

these two principles are central to the most pressing ethical dilemma associated with

preservation of client safety in high risk situations.

Rationale of Current Research and Hypotheses

There is a growing body of research that has examined therapists’ willingness to

intentionally access client online information, their reasons for doing so, how th use the

information, whether they disclose their behaviors to their clients, and the outcomes of

their conduct. There are also some findings that help to explain the considerable variance

among therapists with regard to such behaviors. However, there is very limited research

examining clinicians’ willingness to access and use client SM material specifically to

inform risk-related assessment and intervention decisions, and none regarding the

predictors of doing so.

The present study was conducted in an effort to assess licensed and training

psychologists' self-reported probability that they would 1) access and utilize client SM

content to inform suicide risk-assessment and 2) conduct a digital welfare check when

there is reasonable concern for their client's immediate safety. The likelihood of therapist

engagement in these two behaviors was based on participant responses to two separate

vignettes. Each vignette described a clinical situation in which the participant is asked to

assume the role of therapist for a client who poses indications of potential suicide risk.

The effects of the following predictors on that likelihood were investigated: participant

digital literacy (level of experience and comfort navigating online social environments),

professional status (licensed psychologist versus psychologist-in-training), theoretical

orientation, and the degree of reliance on each of the APA general ethical principles

when responding to each vignette. The first two predictors (digital literacy and

professional status) serve as alternative, and hopefully more explanatory, characteristics

for participant age. The findings are discussed in terms of the potential ethical and

clinical implications for practitioners and trainees, practice and training recommendations

for psychologists, and suggestions for the revision of the APA Ethical Principles for

Psychologists and Code of Conduct.

Hypotheses

Given the limited existing research regarding the frequency, reasons, and

outcomes of clinicians accessing client online information through SM, as well as some

of the therapist factors that predict them, and the relative dearth of research regarding

such practices in the specific context of suicide risk, the following hypotheses were

offered:

Hypothesis 1

Under the conditions of Vignette A (SM-informed risk assessment), participants

as a whole would report being unlikely to conduct a SM-informed risk assessment. That

is, 51% or more of all participants will rate their likelihood as 49% or lower. This

hypothesis was based on previous research indicating that clinicians are generally

reluctant to engage with their clients online for any reason (Kolmes & Taube, 2014;

Tunick, Mednick, & Conroy, 2011; Wu & Sonne, 2019), as well as the lack of specific

ethical standards for psychologists related to this issue.

Hypothesis 2

Under the conditions of Vignette B, participants as a whole would report a

relatively low likelihood of conducting a digital welfare check. Specifically, 51% or more

of all participants will rate their likelihood as 49% or lower. The rationale for this

hypothesis was the same as hypothesis 1.

Hypothesis 3

There would be a significant difference between participant likelihood to conduct

a SM-informed risk assessment and likelihood to conduct a digital welfare check.

Specifically, it was hypothesized that participants would report being significantly more

likely to conduct a digital welfare check, compared to a SM-informed risk assessment.

This hypothesis was based on current ethical principles and standards (APA, 2017) and

theoretical frameworks of morality (Jones 1991; Hodgkinson, 1996), that, when applied,

suggest that the temporal urgency and potential consequences of a client being in

immediate danger may increase the likelihood of the clinician intervening. In the case of

a digital welfare check, the clinician already obtained information indicating that the

client may be at immediate risk, whereas, in an SM-informed risk assessment, the

clinician would access their client's SM profile to help them determine risk level, but

without evidence of immediate risk.

Hypothesis 4

There would be an effect of digital literacy on participant likelihood that they

would conduct both an SM-informed risk assessment and a digital welfare check. It was

expected that the higher a participant rated their digital literacy, the higher their reported

likelihood of conducting both forms of SM access would be. Digital literacy represents an

elaboration on the concept of digital identity (digital native vs. digital immigrant), in that

it aims to capture participants who may have been born or grew up before the mass

introduction of social technology, but have since worked to develop their familiarity with

and understanding of SM. This hypothesis was informed by research that suggests that

digital natives are more likely to be familiar with online cultural norms (Jent et al., 2011;

Kolmes & Taube, 2014), and, thus, may be more likely to view SM as an adequately

valid resource for risk-related information.

Hypothesis 5

Participant professional status would significantly predict participant likelihood of

engaging in both an SM-informed risk assessment and a digital welfare check. Training-

level participants would be significantly more likely to conduct both forms of SM access,

compared to licensed participants. This hypothesis was based on previous research from

Jent et al. (2011) and DiLillo & Gale (2010), which found that training level clinicians

are more likely to conduct online client searches.

Hypothesis 6

There would be a significant relationship between the degree of participant

identification with each theoretical orientation, and their reported likelihood of engaging

in both forms of SM access. Specifically, it was proposed that the more a participant

identified as humanistic-experiential, the more likely they would be to conduct both

forms of SM access. Conversely, the more a participant identified as

psychodynamic/psychoanalytic or CBT, the less likely they would be to conduct both

forms of SM access. This hypothesis was informed by core tenants of both

psychoanalytic and psychodynamic theory and practice related to avoiding contamination

of the therapeutic space with potential boundary crossings, as well as literature

suggesting that psychoanalytic/psychodynamic therapists are less likely to engage in

behaviors that may constitute a boundary crossing, while humanistic-experiential

therapists are more likely to do so (Ziv-Beiman, 2013). Furthermore, this hypothesis was

also based on the work of Kolmes & Taube (2014), who found that CBT therapists were

less likely to intentionally search for clients online compared to psychodynamic

therapists, as well as findings from Eichenberg & Herzberg (2016) that demonstrate that

psychoanalytic and psychodynamic therapists were less likely to perceive online client

searches as justifiable in any situation than CBT therapists.

Hypothesis 7

There would be a significant effect of the degree to which participants relied on

two of the general ethical principles as they considered the vignettes posing a potential

for a SM-informed risk assessment and a digital welfare check. Specifically, the higher a

participant rated Beneficence and Nonmaleficence in terms of importance to their

decision-making, the more likely they would be to engage in both a SM-informed risk

assessment and a digital welfare check. Conversely, the higher a participant ranked

Respect for Peoples' Rights and Dignity in terms of importance to their decision-making,

the less likely they would be to engage in both a SM-informed risk assessment, and a

digital welfare check. It was proposed that there would be no significant effect of level of

importance for all other general principles on willingness to engage in both a SM-

informed risk assessment and a digital welfare check. These hypotheses were again

informed by current ethical standards (APA, 2017), as well as Jones's (1991) and

Hodgkinson's (1996) theoretical frameworks of morality that, when applied, suggest that

individuals who rank Beneficence and Nonmaleficence at the top of their ethical rankings

would be more likely to prioritize preservation of client safety, while participants who

rank Respect for Peoples' Rights and Dignity at the top of their rankings would be more

likely to prioritize preservation of client privacy and confidentiality.

CHAPTER TWO

Methods

Participants

In total, 139 individuals responded to recruitment invitations: 72 doctoral-level,

licensed or certified psychologists, and 67 psychologists-in-training (in doctoral level

graduate programs). They were recruited from four sources: 1) 13 email listservs from

various professional psychology associations (see Appendix H for full list of listservs), 2)

100 Facebook groups whose members include doctoral level clinicians (i.e., with a

Psy.D., Ph.D., or Ed.D. degree; see Appendix I for the full list of Facebook groups

contacted), and 4) snowball sampling through five faculty in the Department of

Psychology, School of Behavioral Health, Loma Linda, CA. Reminders were sent out

until 139 participants are recruited; this number represented 41 additional participants

over the number needed for the proposed statistical analyses (N = 98), in order to account

for invalid responses and incomplete questionnaires.

Measures

Social Media-Informed Risk Assessment Vignette (Vignette A)

Participants were presented with a fictional vignette and asked to imagine that

they are the therapist in the situation (See Appendix C). The vignette depicted a situation

in which, during an intake session, a young adult client endorses some risk factors for

suicide, but is hesitant to discuss the issue further, leaving the client’s risk-level

ambiguous. The fictional client also endorsed heavy and frequent social media use. Based

on situational factors of the vignette, the participants were asked how likely (on a scale of

0 to 100) they would be, based on the information presented in the vignette, to search for

and access their client’s SM profile outside of the therapy session in an effort to gather

additional information that could inform the determination of risk level.

Digital Welfare Check Vignette (Vignette B)

Participants were presented with a second vignette, where they were asked to

imagine that they are working with a fictional young adult client previously determined

to be at moderate-to-high risk for suicide (See Appendix D). The fictional client also

endorsed heavy and frequent social media use. Participants were told that the client has

been regularly attending weekly therapy for eight weeks, and that the client's suicidality

has been a primary topic addressed during therapy. Participants were also told that,

following a particularly emotion-laden session, the fictional client unexpectedly no-

shows for the following session and that their attempts to contact the client by phone,

email, and text were unsuccessful. Based on this information, participants were asked

how likely (on a scale of 0 to 100) they would be to search for and access the fictional

client's social media page, in an effort to obtain information that could help determine

whether the client is at immediate risk for suicide, and if additional protective measures

are clinically indicated.

General Ethical Principles Questionnaire

Following the completion of the second vignette, participants completed the

General Ethical Principles Questionnaire (See Appendix E). Respondents read

descriptions of each of the five APA General Ethical Principles and rated each principle

on a scale of 0 - 100, based on how much each influenced their reported likelihood of

accessing the client’s SM information under the conditions presented in each of the two

vignettes. Participants were then prompted to ensure that their ratings for each principle

add up to 100 for each of the two vignettes.

Vignette Follow-Up Questionnaire

On this questionnaire, participants were asked to complete one follow-up question

for each vignette. Each question asked the degree to which the participant’s likelihood

rating would have changed if they had read in the vignette an explicit statement that the

client had been informed of and agreed to the therapist’s practice of accessing the client’s

social media profile in situations of possible suicide risk?

Therapist Characteristics Questionnaire

This questionnaire (see Appendix G) included items requesting information

regarding participants' general demographic information (i.e., age, gender, ethnicity,

educational degree level(s) and field(s), licensure status, and state of practice or training),

theoretical orientation and digital literacy and use.

In addition to basic demographic information, participants were also asked to

designate the degree of their use of the following theoretical orientations in the

conceptualization and treatment of their clients (Likert scale 0 to 100): Humanistic-

Experiential, Cognitive-Behavioral, Psychodynamic/Psychoanalytic, and other.

Participants were prompted to ensure that their ratings of each option add up to a total of

100.

In addition, participants were asked to rate on a Likert scale (0-100) the level to

which they understand and are comfortable navigating online social platforms and the

communicative patterns found within those platforms (digital literacy). This construct

represented an elaboration on the concepts of digital native vs. digital immigrant, in that

it aimed to capture participants who may have been born or grew up before the mass

introduction of social technology (making them digital immigrants), but have since

worked to develop their digital knowledge and skills. Participants were also asked

identify which digital SM platforms they currently use and how often per week.

Procedures

As described above, participants were recruited through the American

Psychological Association listservs for professionals and graduate students, the APPIC

listserv, Facebook groups with members who are both in training and doctoral level,

practicing clinicians, and snowball sampling initiated by various faculty in the

researcher’s graduate department (See Appendix A). Participants were provided with a

link that redirects them to a Qualtrics website that provides an informed consent

document detailing the purpose and nature of the study, the approximate time required to

complete the survey materials, the potential risks and benefits associated with

participation in the study, and procedures for completing the survey (See Appendix B).

Upon reading the informed consent form and agreeing to participate (passive

consent by proceeding to the study vignettes), participants were presented with Vignette

A, and asked to rate their likelihood of engaging in a SM-informed risk assessment based

on information in the vignette. Then participants were then presented with Vignette B and

asked to rate their likelihood of engaging in a digital welfare check of the client based on

the information in the vignette. Participants then were administered the General Ethical

Principles Questionnaire, followed by the Vignette Follow-up Questionnaire, and the

Therapist Characteristics Questionnaire.

In sum, participant tasks were ordered as follows: Read and acknowledge the

Informed Consent form, read Vignette A, rate likelihood that they would engage in a SM-

informed risk assessment, read Vignette B, rate likelihood that they would engage in a

digital welfare check, and complete the General Ethical Principles Questionnaire, the

Vignette Follow-up Questionnaire, and the Therapist Characteristics Questionnaire. Any

apparent invalid responses were eliminated from the study (e.g., random responding), and

any survey that is not at least 80% completed will also be excluded from the data

analyses process.

Data Analysis

The data was first analyzed for invalid responses. A survey questionnaire was

determined invalid if it appeared that individual responses were randomly produced or if

the participant failed to respond to 80% of questions. The data set was then analyzed for

missing responses. Finally, some demographic variables were redefined due to low

response frequency.

Invalid Data Analyses

A total of 139 individuals responded to the initial invitation for participation and

engaged with the Qualtrics survey. In order to minimize invalid data, the Qualtrics survey

was structured in a manner that did now allow respondents to advance unless the item

was answered in a valid manner (e.g., ethical principle ratings needed to add up to a sum

of 100 before respondents could advance to the next item). Overall, 23 questionnaires

were excluded due to the participants apparently discontinuing the survey and failing to

respond to at least 80% of the questions. The final total sample consisted of 116

respondents who submitted valid questionnaires, 66 licensed and practicing psychologists

and 50 in doctoral level graduate training programs.

Missing Data Analysis

Overall, two participants did not disclose their ethnicity, one did not disclose their

most advanced degree, four did not disclose their geographic location, and one did not

disclose their digital literacy.

Demographic Variable Transformations

Two demographic variables were transformed due to low response frequencies.

First, only two participants identified as “Asian/Indian Subcontinent.” Therefore, that

ethnicity category was combined with the “Asian/Southeast Asia or Far East” category,

and the variable was relabeled “Asian.” There were also low response frequencies for

some participants’ reported state of practice. Therefore, states were assigned to their

respective US Census Bureau geographic region and participants from those states were

grouped together into their respective region. Participants who reported practicing in

California, Arizona, Utah, and Washington were relabeled “West”; participants who

reported practicing in Illinois, Iowa, and Ohio were relabeled “Midwest”; participants

who reported practicing in Texas, Arkansas, Delaware, Virginia, and North Carolina

were relabeled “South”; and participants practicing in New York, Pennsylvania, New

Jersey, New Hampshire, and Massachusetts were relabeled “Northeast.”

CHAPTER THREE

Results

Sample Characteristics

Demographic data for the final total sample of participants using transformed

demographic variables are presented in Table 1.

Table 1

Demographic Data for Respondents

(N = 116)

Demographic Characteristics

(SD)

Age (years)

34.40

9.15

Digital Literacy

79.46

20.92

Theoretical Orientation

CBT

55.72

28.64

Humanistic-Experiential

20.28

20.45

Psychodynamic/Psychoanalytic

7.46

10.65

Other

16.54

15.88

Gender

Male

25.0

Female

71.6

Transgender and

Nonconforming

1.7

Prefer not to answer

1.7

Professional Status

Licensed

56.9

In-training

43.1

Ethnicity

Asian

14.6

Middle Eastern

4.3

Black or African American

4.3

Hispanic/Latino

6.0

White or Caucasian

60.3

Mixed

8.7

Missing

1.7

Most Advanced Degree

Bachelors

3.4

Masters

25.0

Ph.D.

36.2

Psy.D.

34.5

Missing

0.9

U.S. census bureau/location

Northeast

12.1

Midwest

1.7

South

7.8

West

75.0

Missing

3.4

Frequency Analyses and Likelihood Comparisons

In order to explore hypotheses 1 and 2, frequency analyses were conducted to

identify how many participants reported being likely to conduct (1) a social-media

informed risk assessment and (2) a digital welfare check (based on the information

presented in vignettes 1 and 2, respectively). A participant was defined as “likely” to

conduct either form of social media check if they reported a likelihood of 50% or greater

(out of 100%), and they were defined as “unlikely” if their reported likelihood score was

49% or less (continuous likelihood was dichotomized accordingly). Overall, the majority

of respondents reported being unlikely to conduct either a social media-informed risk

assessment or a digital welfare check. Results are reported in Table 2.

Hypothesis 3 proposed that participants would report being significantly more

likely to conduct a digital welfare check compared to a SM-informed risk assessment.

Due to a violation of the assumption of normality for both the social media-informed risk

assessment and the digital welfare check likelihoods, a Wilcoxon Signed Ranks Test was

conducted to test this hypothesis. A Wilcoxon Signed Ranks Test indicated that

participants were significantly less likely to conduct a social media-informed risk

assessment (M = 19.34, SD = 27.24) than a digital welfare check (M = 26.22, SD =

34.75), z = -3.54, p < .001.

Table 2

Results of Frequency Analysis of Participants’ Likelihood Ratings

Vignette Type

n (%)

Vignette 1 (Social Media-Informed Risk Assessment)

Likely

22 (19.0%)

Unlikely

94 (81.0%)

Vignette 2 (Digital Welfare Check)

Likely

31 (26.7%)

Unlikely

85 (73.3%)

Note: “Likely” is defined as a likelihood score of 50 or greater; “unlikely” is

defined as a likelihood of 49 or less

Multiple Linear Regression Analyses

In order to test hypotheses 4 through 7, two separate multiple linear regression

(MLR) analyses were initially proposed in order to test the effects of allegiance to each

ethical principle, digital literacy, professional status, and theoretical orientation on

participant likelihood to (1) conduct a social media-informed risk assessment and (2)

conduct a digital welfare check.

Due to violations of assumptions of normality and collinearity, as well as

difficulties with model fit, some of the variables included in the proposed analyses were

excluded from the final MLR analyses. The final regression model for both dependent

variables met all statistical assumptions, and consisted of (1) importance rating of

Beneficence, (2) importance rating of Respect for Peoples’ Rights and Dignity, (3) digital

literacy (4) professional status (dichotomized; licensed vs. unlicensed), (5) participant

identification with CBT theoretical orientation, (6) participant identification with

Psychodynamic/Psychoanalytic theoretical orientation, and (7) participant identification

with Humanistic/Experiential theoretical orientation.

Results for Social Media-Informed Risk Assessment

Using the enter method, the results of the MLR analysis revealed that

participants’ importance rating of Beneficence and Respect for Peoples’ Rights and

Dignity, digital literacy, professional status, and identification with CBT,

Psychodynamic/Psychoanalytic, and Humanistic/Experiential theoretical orientations

explained a significant amount of the variance in likelihood to conduct to a social media-

informed risk assessment, (F(7, 108) = 9.04, p < .001, R

= .37).

Furthermore, the analysis showed that Beneficence significantly (positively)

predicted likelihood of conducting a social media-informed risk assessment (b = .532,

t(108) = 4.76, p < .001); a .532 increase in Beneficence resulted in a 1 point increase in

likelihood of conducting a social media informed risk assessment. Participant likelihood

of conducting a social media-informed risk assessment was not significantly predicted by

Respect for Peoples’ Rights and Dignity, digital literacy, professional status, or

identification with any of the theoretical orientations entered into the analysis (CBT,

Psychodynamic/Psychoanalytic, Humanistic/Experiential). Results are presented in Table

Table 3

Results of Multiple Linear Regression Analysis for Social Media-Informed Risk

Assessment

Predictor

beta

Fit

(Intercept)

7.180

Beneficence*

.532

.477

.132

Respect for Peoples’ Rights and Dignity

-.149

-.131

.010

Professional Status

3.401

.062

.004

Digital Literacy

-.050

-.032

.001

CBT

.017

.018

<.001

Humanistic/Existential

.166

.124

.006

Psychodynamic/Psychoanalytic

-.147

-.057

.002

= .369*

* indicates p < .001

Results for Digital Welfare Check

The same multiple linear regression model was used to predict participants’

likelihood to conduct a digital welfare check. Using the enter method, the results

indicated that participants’ importance rating of Beneficence and Respect for Peoples’

Rights and Dignity, digital literacy, professional status, and identification with CBT,

Psychodynamic/Psychoanalytic, and Humanistic/Experiential theoretical orientations

explained a significant amount of the variance in likelihood of conducting a digital

welfare check, (F(7, 108) = 11.68, p < .001, R

= .43).

Furthermore, the analysis again showed that Beneficence significantly (positively)

predicted the likelihood of conducting a digital welfare check (b = .667, t(108) = 5.01, p

< .001). Specifically, a 1 point increase in Beneficence resulted in a .667 point increase

in likelihood to conduct a digital welfare check. Respect for Peoples’ Rights and Dignity

also significantly (negatively) predicted likelihood of conducting a digital welfare check

(b = -.274, t(108) = -1.99, p < .05); a 1 point increase in Respect for Peoples’ Rights and

Dignity results in a .274 point decrease in likelihood to conduct a digital welfare check.

Participant likelihood of conducting a digital welfare check was not significantly

predicted by digital literacy, professional status or identification with any of the analyzed

theoretical orientations. Results are presented in Table 4.

Table 4

Results of Multiple Linear Regression Analysis for Digital Welfare Check

Predictor

beta

Fit

(Intercept)

3.618

Beneficence**

.667

.482

.132

Respect for Peoples’ Rights and Dignity*

-.274

-.192

.020

Professional Status

8.335

.119

.013

Digital Literacy

.120

.072

.004

CBT

-.103

.085

.002

Humanistic

.035

.021

<.001

Psychodynamic/Psychoanalytic

-.524

-.161

.015

= .431**

** indicates p < .001; * indicates p < .05

CHAPTER 4

Discussion

Current Study

This study was designed to explore the ethical attitudes of psychologists and

psychologists-in-training ethical toward utilizing clients’ online data to aid clinical

navigation of suicide risk situations. Specifically, participants were asked to rate their

likelihood of engaging in two distinct forms of gathering client digital data. The first was

a social media-informed risk assessment, where the clinician accesses the client’s social

media profile to inform determination of suicide risk level, especially when risk-related

information acquired in-person is ambiguous or incomplete. The second was a digital

welfare check, where the clinician accesses the client’s social media profile in an effort to

determine the location and condition of a client previously determined to be at high

suicide risk. Moreover, participants were asked to identify the general ethical principles

that most aided their likelihood determination for both forms of social media checks, as

well as their relative identification with four major theoretical orientations (CBT,

Humanistic/Existential, Psychodynamic/Psychoanalytic, and Other), in order to explore

whether the variables had any effect on those likelihood ratings. Finally, participants

were asked to complete items related to basic demographics, digital literacy, and several

professional characteristics, such as if they are licensed and in what state they practice.

This study was conducted as an extension and elaboration of many previous

bodies of research. First, we attempted to expand on information regarding clinicians’

willingness to check clients’ social media profiles, especially in risk situations (DiLillo &

Gale, 2010; Eichenberg & Herzberg, 2016; Ginory, Sabatier, & Eth 2012; Kolmes and

Taube, 2014; Lehavot et al., 2010; Tunick et al., 2011; Wu & Sonne, 2019). We also

aimed to add to the current literature regarding different ways that clinicians could

potentially use clients’ social media to inform client risk level (Coppersmith, Leary,

Crutchley, & Fine, 2018; De Choudery et al., 2016; De Choudhury et al., 2013; Gunn &

Lester, 2012; Moreno et al., 2011; Vioulés, Moulahi, & Bringay, 2017). And, we aimed

to continue the investigation of ethical, professional, and moral considerations relevant to

potentially breaching client confidentiality in risk situations, and how these

considerations can potentially inform future discussions within the field of psychology

regarding the development of new ethical guidelines (Gottlieb, 2011; Hadjistavropoulos,

2011; Hodgkinson, 1996; Jones, 1991; Kaslow, Patterson, & Malloy et al., 2002; Sinclair

et al., 1987; Thelen et al., 1994; Williams et al., 1996; Woolfolk, 1998). Finally, our

findings can be especially relevant, given the recent expansion of telehealth in response

to the COVID-19 pandemic for two reasons. First, it is likely that helping professionals

will increasingly find themselves exploring virtual methods of securing the safety of their

clients, and second, helping professionals should strive to remain abreast of the rapidly

evolving ethical and professional considerations related to digital practice.

The results for the seven hypotheses are discussed first below. Then, the

limitations of the study are outlined. Finally, the Discussion concludes with the potential

implications of this study for clinical training and for future research.

Discussion of the Results of the Hypotheses

Generally, psychologists and other mental health professionals have expressed

hesitance to utilize client social media, for both personal and professional reasons

(Eichenberg & Herzberg, 2016; Ginory, Sabatier, & Eth, 2012; Wu & Sonne, 2019). The

results of this study further support those findings, as well as our own hypotheses, in that

the majority of participants reported that they were unlikely to conduct a social media

informed-risk assessment or a digital welfare check, even after it was made clear that the

fictional clients in each vignette may be at risk for suicide.

Despite participants’ general low likelihood of conducting either form of social

media checks, results indicated that participants were significantly more likely to conduct

a digital welfare check than a social media-informed risk assessment. This is most likely

due to the importance of clients’ actual risk level in deciding whether to conduct a social

media check. Vignette B was written to illustrate a higher level of risk for the fictional

client than in vignette A, which may have led participants to feel more obligated to

intervene to ensure the safety of the client. In contrast, participants may have found that

the risk level conveyed in vignette A was not severe enough to justify checking the

client’s social media profile. Indeed, this explanation is at least partially supported by

Jones’ (1991) and Hodgkinson’s (1996) theoretical frameworks of morality. In applying

these frameworks to clinical work, temporal urgency and the magnitude of consequence

are primary factors relevant to clinicians’ decisions related to navigating suicide risk.

Thus, the temporal urgency and magnitude of consequence may have been more salient

to participants while reading vignette B, where risk level was already established and the

fictional client’s behaviors were especially concerning, compared to vignette A, where

risk-relevant information was more ambiguous.

The overall regression models significantly predicted therapists’ and therapists’-

in-training likelihood of conducting both a social media-informed risk assessment and a

digital welfare check. More specifically, the results indicated, as hypothesized, that

participants’ relative value placed on the general ethical principle of Beneficence (duty to

protect) significantly predicted their likelihood to conduct both forms of social media

checks, in that the higher the participant rated Beneficence, the more likely they were to

conduct either check. This would be expected, given that Beneficence is an especially

important ethical principle in the context of navigating client suicide risk, and a higher

allegiance to Beneficence would reasonably lead a clinician to be more liberal with

protective actions. Interestingly, according to the research (Hadjistavropoulos [2011],

Hadjistavropoulos & Malloy [1999], and Seitz & O'Neill [1996]), the duty to protect

ranks high among Canadian psychologists, as well as in the Canadian Psychological

Association’s code of ethics, which further supports the importance of Beneficence in

clinicians’ general clinical and ethical decision-making.

As hypothesized, participants’ relative value placed on the general ethical

principle of Respect for Peoples’ Rights and Dignity significantly (negatively) predicted

their likelihood of conducting a digital welfare check, in that the higher the value placed

on Respect for Peoples’ Rights and Dignity, the lower their likelihood to conduct a digital

welfare check. Value placed on Respect for Peoples’ Rights and Dignity also negatively

predicted likelihood of conducting a social media-informed risk assessment, though this

result was not significant. These results are expected, given that Respect for Peoples’

Rights and Dignity is also a particularly important ethical principle, both in its relation to

general ethical decision-making and especially in situations involving client suicide risk.

Respect for Peoples’ Rights and Dignity encapsulates a clinician’s obligation to respect a

client’s privacy and protect their confidentiality, unless it is necessary to violate privacy

or breach confidentiality to ensure the safety of a client. Currently, methods of

determining and responding to suicide risk level for clients are highly subject to clinician

judgment. Therefore, whenever clinicians are deciding whether or not to violate privacy

or breach confidentiality in the case of an at-risk client, they are considering both the

circumstantial factors of the case, as well as weighing the general ethical principle of

Respect for Peoples’ Rights and Dignity against the principle of Beneficence.

As noted, while Respect for Peoples’ Rights and Dignity was negatively

associated with therapists’ likelihood of conducting a social media-informed risk

assessment as hypothesized, the association was not significant. This result may again be

due to the therapist’s perception of actual risk to the client as posed in vignette B

compared to vignette A. Participants may have been more intentional in their

consideration of all of the ethical principles while responding to vignette B, compared to

vignette A, given that risk posed by the fictional client in vignette B was more magnified.

Despite these findings regarding the relative value of Beneficence and Respect for

Peoples’ Rights and Dignity in the prediction of psychologists’ conduct of social media

checks, some significant caveats exist related to these results. Though the effects of the

principles of Integrity, Justice, and Fidelity and Responsibility could not be analyzed due

to statistical limitations, some participants provided qualitative information underlying

their likelihood scores for both forms of social media checks. Specifically, some

participants’ text responses indicated the importance of a lack of informed consent as

described in the vignettes to determining their likelihood scores. Some participants wrote

that the fact that the fictional clients were not made aware beforehand of the possibility of

them conducting a social media-informed risk assessment or a digital welfare check was

the primary reason they provided a low likelihood score. Given that informed consent is

an issue that has implications across multiple ethical principles, it is possible that the lack

of informed consent superseded all other ethical considerations for some participants, and

thus diluted some of the variance in the ratings of the general ethical principles. More

formal statistical and qualitative analyses would be needed to further explore this

possibility. Additionally, some participants wrote that conducting a social media check of

any kind runs the risk of compromising professional boundaries and contaminating the

therapeutic relationship, another issue that could have affected likelihood scores that

touches multiple ethical principles.

None of the analyzed theoretical orientations had any significant effect on

likelihood scores for either form of social media check. These results conflict with our

hypothesis that identification with a Humanistic theoretical orientation would

significantly positively predict likelihood for both forms of social media check, and that

identification with CBT or Psychodynamic/Psychoanalytic theoretical orientations would

significantly negatively predict likelihood to conduct both forms of social media check. A

potential explanation for these findings is that, though clinicians of different theoretical

orientations may approach assessing suicide risk differently, navigating client suicide risk

and ensuring client safety is more of an issue of general ethics than an issue of specific

therapeutic approach and technique. Therefore, it is a reasonable that participants’

likelihood scores may have been more influenced by ethical considerations and the

circumstances of the vignettes, rather than this particular professional factors.

Results also indicated no significant relationships between professional status (i.e.

being licensed vs. unlicensed) and self-reported digital literacy, and the two social media

checks. Regarding professional status, it is possible that both licensed and unlicensed (in

training) clinicians were equally sensitive to the circumstantial factors and ethical

considerations associated with each vignette, and, thus, responded similarly in terms of

likelihood scores. Digital literacy was most likely not a significant predictor due to a lack

of variance; the vast majority of respondents identified themselves as having a high level

of digital literacy. This would be expected, as digital immigrant clinicians are likely to

have learned how to navigate and use social media (and other technologies) over time in

their professional work and personal lives.

Implications for Clinical Work

Based on the findings of this study, it remains true that clinicians generally are

reluctant to access clients’ digital information to inform clinical decision-making, even in

cases of elevated suicide risk. Results also indicate that relative allegiance to general

ethical principles have a greater bearing on willingness to digitally violate privacy or

breach confidentiality, rather than any demographic or professional factors.

The most immediate implication of this study relates to procedural practices in

clinical work, especially in situations where elevated suicide risk is a factor. Participants

appear to be willing to consider conducting a social media-informed risk assessment or a

digital welfare check, depending on the urgency of the risk situation and their ethical

sensitivities. However, it may be argued that all clinicians, regardless of baseline

willingness to conduct a social media check, may benefit from incorporating such

practices into their practice. Given the findings that suggest that individuals are turning to

social media to discuss their innermost struggles, as well as the increasing digitization of

helping professions, both during the COVID-19 pandemic and beyond, adding social

media checks to one’s clinical work can assist in providing the best possible care and

ensuring the safety of at-risk clients. Importantly, however, consistent with some

participants’ narrative responses, therapist access to clients’ social media must be

included informed consent documents, in order to ensure the ethicality of the practice.

Overall, our results, along with current ethical principles and standards, suggest that there

may be ways to incorporate social media accessing into clinical practice, but that the

circumstances underlying such access, the scope of the access, and the therapist’s final

clinical decision based on the results of the access remain subject to clinical judgment.

Therefore, access to clients’ social media represents an opportunity to increase the safety

of their clients, while still reasonably protecting client privacy and confidentiality.

The informed consent process for the use of a client’s social media in the context

of potential suicide risk must clearly outline the clinician’s approach to accessing the

social media, the scope of the check, and exactly how the information accessed may be

used. For example, a clinician who wishes to use social media in their practice would

need to clearly outline to their clients whether or not they would bring other potentially

clinically relevant issues into therapy after conducting the access, even if those issues are

not relevant to the client’s suicide risk. Furthermore, clinicians would need to set

boundaries with their clients regarding how often they would conduct a check and how

much content would be reviewed. And, finally, clinicians would need to clearly think

through the potential clinical, ethical, and legal issues inherent in opening a whole

domain of information regarding their client for which they may then be professionally

responsible, but may not be able reasonably monitor given time and other situational

constraints.

A second implication of this study relates to the codification of general ethical

principles or ethical standards regarding digital practice. Currently, other mental health

professions have explicit standards or recommendations related to digital practice. One

aim of this study was to spark conversations in the field of psychology, in order to

prompt the profession to create and publish digitally-informed principles and standards in

future iterations of the ethics code. Doing so would provide clinicians who want social

media to play a more active role in their clinical work more concrete ethical and

professional guidance, as well as help them identify and reduce the risks of doing so.

Finally, this study was also conducted as an exploration into whether clinicians’

attitudes toward the utility of social media matches empirical findings regarding that

utility of social media in assessing or predicting suicide risk. As previously discussed,

research suggests that people are becoming increasingly transparent on social media, and

other researchers have already begun investigating other ways that social media can be

used to assess suicide risk. For example, computer scientists and linguists are developing

algorithmic models for assessing or even predicting suicidality based on individuals’

online language patterns, and these models have been validated and found to be accurate.

Of note, these models represent a more objective approach to understanding the

relationship between suicidality and online behaviors, while social media checks

conducted by clinicians are largely subjective, both in the determination of actual risk

based on the gathered information, and subsequent clinical decision-making. However,

there may be opportunities in the future to blend these two approaches and mitigate the

limitations of each. For example, clinicians may learn to utilize some of these models to

more accurately assess risk, in order to minimize ethical ambiguity and the role of

subjective judgment. They would then be able to use the privileges afforded by the

therapeutic relationship to make more accurate and appropriate clinical decisions. Finally,

psychologists may benefit from developing and validating objective measures of social

media use, reasons for social media use, and the degree to which clients’ social media

behaviors mirror their real-life behaviors.

Limitations and Future Directions

This study was conducted with multiple limitations, particularly statistical in

nature. As previously discussed in the results section, many of the variables did not meet

statistical assumptions for analysis. Of particular importance was the exclusion of the

general ethical principles of Integrity, Justice, and Fidelity and Responsibility. It is

possible that the relative value placed on these principles also had an effect on likelihood

scores, and follow-up studies should be conducted that either transform variables that do

not meet statistical assumptions, or that modify the operationalization of the principles to

facilitate analysis.

There are also limitations related to recruitment and the sample itself. The APA

has noted that many psychologists are not members of an APA division, and even

psychologists who are members of a division do not subscribe to the division’s listserv.

As such, caution must be used in generalizing the findings to all psychologists.

Furthermore, the APA notes that many members of an APA division are not doctoral-

level clinicians or clinicians in doctoral training. Though this study attempted to exclude

non-doctoral clinicians or trainees, it is possible that non-doctoral clinicians or trainees in

a Masters program completed the survey. Future studies may extend recruitment beyond

those used in this research to obtain a more general sample of practicing psychologists

and those in training.

Regarding the characteristics of the sample itself, the majority of respondents

identified as White. Furthermore, the majority of respondents reported that they practice

in the western region of the United States. The majority of participants also identified as

Female. Future studies should be conducted that attempt to gather a more heterogenous

sample in regards to gender, ethnicity, and geographic location.

Another possible limitation of this study may have resulted in the failure to find

theoretical orientation of the therapist as a predictor of either type of accessing social

media. We chose to operationalize theoretical orientation as we did in order to

accommodate therapists who are influenced by more than one in their practice.

Unfortunately, this method likely diluted the variance associated with each. Future

research may introduce other creative ways to operationalize this variable. Finally, future

studies should be conducted in order to elaborate on other factors that may influence

digital behaviors, such as years in clinical practice, training in professional technology

practices, primary population with which therapist participants work (e.g., youth vs. adult

clients), and the potential influences the current COVID-19 pandemic may have on their

willingness to engage in such behaviors.

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APPENDIX A

Listserv and Snowball Email Recruitment Notice to Participants

Hello:

You are invited to participate in an important study on decision-making in practice

regarding the use of client online information in the context of potential suicide risk. The

study is my Dissertation research project. The study has been approved the Loma Linda

University IRB.

INFORMATION ABOUT THE STUDY:

This study will examine how therapists make decisions in their practice regarding

accessing client information online. The intent is to examine psychologists’ inclinations

to engage in such conduct and the impact of certain psychologist characteristics in their

decision-making process. You were selected to participate due to your standing as a

currently practicing licensed or certified psychologist with a doctoral degree (i.e., Ph.D.,

Psy.D., Ed.D.), or as a psychology trainee in a doctoral graduate program currently

engaged in supervised training. If that is not the case, please do not proceed with the

study.

HOW TO GET INVOLVED:

Please go to the following website to access the survey:

https://llu.co1.qualtrics.com/jfe/form/SV_9uDwj2plDPRi1SZ

It will take approximately 15 minutes of your time. You will be asked to read two short

clinical vignettes and then answer one question following each vignette. You will then be

asked to respond to a questionnaire that poses two questions regarding what may have

contributed to each of your vignette answers. You will then complete some demographic

information and other questions regarding your clinical practice experiences.

Please take a few minutes now to visit the website and complete the survey.

In addition, I invite you to forward this email to any licensed psychologist colleagues or

doctoral level clinical psychology graduate students who meet the criteria for inclusion in

this study and might be willing to participate.

THANK YOU IN ADVANCE FOR VISITING THE STUDY WEBSITE!

Sincerely,

Jacob Vermeersch, M.A.

Loma Linda University

Loma Linda, California

Facebook Recruitment Post

Hello everyone!

Please consider helping me with my dissertation research study investigating therapists’

decision-making in practice regarding the use of client online information in the context

of potential suicide risk. Participation is expected to take only about 15 minutes of your

time.

I am a Ph.D. clinical psychology graduate student in the Department of Psychology at

Loma Linda University. I am recruiting doctoral-level licensed or certified psychologists

who are currently practicing and psychology trainees in a doctoral graduate program

currently engaged in supervised training to participate in my dissertation survey study,

chaired by Dr. Janet Sonne.

Here is a link to the study: https://llu.co1.qualtrics.com/jfe/form/SV_9uDwj2plDPRi1SZ

This study has been approved by Loma Linda University’s IRB.

Thank you very much for your time,

Jacob Vermeersch, M.A.

Loma Linda University

Loma Linda, California

APPENDIX B

Informed Consent Form

Dear Licensed or Certified Psychologist or Psychologist-in-training:

My name is Jake Vermeersch and I am currently enrolled in the Clinical Psychology

Ph.D. program at Loma Linda University. I am conducting a research project for my

Doctoral Dissertation requirement that will investigate your decision-making in clinical

practice regarding the accessing and use of client online information in the context of a

client’s potential suicide risk. The purpose of this letter is to inform you about this

research project and to invite you to participate. You were selected to participate due to

your current status as a practicing licensed or certified clinical psychologist in the U.S.

with a doctoral degree or a doctoral student in a clinical psychology graduate program

currently engaged in supervised clinical training. Before deciding to give your consent to

participate, please read through the following information carefully and ask any questions

you may have (Please see contact information below).

Purpose of this Study:

The purpose of this study is to collect information concerning how psychologists make

decisions in their practice regarding the accessing and use of client online information in

the context of a client’s potential suicide risk. The intent is to examine psychologists’

inclinations to engage in such conduct and the impact of certain psychologist

characteristics in their decision-making process.

Procedure:

Participation will take approximately 15 minutes of your time. You will be asked to read

two short clinical vignettes and then answer one question following each vignette. You

will then be asked to respond to a questionnaire that poses two questions regarding what

may have contributed to each of your vignette answers. You will then complete some

demographic information and other questions regarding your clinical practice

experiences.

Risks:

The risks of participating in this study are minimal, no greater than those encountered

when you consider and make decisions in your everyday life. Any risks potentially stem

from recalling and disclosing some relatively personal information. There may be times

while completing the survey that you feel uncomfortable while remembering unpleasant

events that may have occurred recently, such as your interactions with a challenging

client or difficult professional decisions you needed to make. If you begin to feel

uncomfortable you have the right to stop at any time during the process if you choose to

do so.

Benefits:

Although there is no direct benefit to you for participating in this study, you will be

providing valuable information that may be beneficial to the understanding of the

decision-making processes inherent in the clinical interaction between therapist and

client, specifically when there is a concern regarding the client’s potential suicide risk.

Participant’s Rights:

Your participation is voluntary; there is no penalty for not participating and you can

choose to withdraw at any time.

Confidentiality:

Confidentiality will be maintained at all times. Neither your name, your email address,

nor IP address will be linked to your survey responses in any way. The answers you

provide will be combined with other participants’ answers in order to conduct group

analyses. Any publications or presentations resulting from this study will refer only to the

grouped results.

Costs/Reimbursement:

There are no costs for taking part in this study nor will you be compensated or

reimbursed for participation.

Impartial Third Party Contact:

If you wish to contact an impartial third party not associated with this study regarding

any concerns you may have about this study, you may contact the Office of Patient

Relations, Loma Linda University Medical Center, Loma Linda, CA 92354, by phone

(909) 558-4647 or e-mail [email protected] for information and assistance.

Informed Consent:

If you have any questions about this project, please do not hesitate to contact me, Jake

Vermeersch at (909) 499-0391 or [email protected], or Dr. Janet Sonne

([email protected]) Research Committee Chair.

If, you decide to discontinue the survey at any time, for any reason, you are free to do so.

If you have any questions regarding this study, we will be happy to answer them. You

are also free to print out the informed consent document for your own review.

Thank you for your time and consideration.

Informed Consent Statement

I have read the contents of the consent form and have been given the opportunity to

ask questions concerning this study. I have been provided an option to print a copy of

this form.

I hereby give my voluntary consent to participate in this study. Filling out this survey

acknowledges my passive consent to participate in this study. This does not waive my

rights nor does it release the investigators or institution from their responsibilities. I

may contact Dr. Sonne ([email protected]) if I have additional questions or concerns.

Janet Sonne, Ph.D. Jake Vermeersch, M.A.

Adjunct Professor Graduate Student

Dept. of Psychology Dept. of Psychology

Loma Linda University Loma Linda University

APPENDIX C

Vignette A (Social Media-Informed Risk Assessment):

Your client has presented to an intake session reporting symptoms of anxiety and

depression stemming from a recent break-up of a romantic relationship, familial conflict,

and academic struggles. The client reports sometimes feeling hopeless about the future

and having frequent thoughts about death and dying. When you reach the topic of suicide,

your client states that they have no prior suicide attempts or hospitalizations, but have

recently been having active suicidal ideation. You begin conducting a risk-assessment,

during which your client states that they experience suicidal ideation "a few times a

week." Your client also denies any concrete suicide plan, but says that they have been

thinking recently about "what the easiest or most painless way to do it would be, if things

get too bad." Your client also denies having any suicidal intent at this time, but says that

“it is not clear how things will turn out if things don't start looking up soon." Your client

endorses having a small group of friends, though admits still feeling "lonely a lot of the

time." Your client reports use of social media to "try and stay connected to people and

have somewhere to just say what I want to say." Concerned about your client's remarks,

you attempt to further assess for risk and protective factors. Your client interrupts you

and says "I don't want to talk about this anymore." Your client asks to end the session

early and declines to complete a safety plan. However, your client assures you that they

are safe, and will try to attend a follow-up session next week.

Based on the information presented, please rate, from 0 (Totally unlikely) to 100

(Totally likely), how likely you would be to conduct a social media-informed risk

assessment by checking your client’s social media profile outside of the therapy session,

in order to obtain more information with which to assess current suicide risk? Please

respond 0-100: _____________

APPENDIX D

Vignette B (Digital Welfare Check)

Your client presented to therapy with symptoms of depression related to struggles with

sexuality. During the intake session seven weeks ago, your client endorsed having

frequent active suicidal thoughts. Your client also endorsed having made a suicide plan

about a year ago, but denied ever having suicidal intent. Your client acknowledged

owning a firearm, and spending a lot of time on social media to "keep (my) mind off

things." Since then, you have established good rapport with your client, and your client

has not yet missed any of the weekly appointments with you. During the course of

therapy, your client has shown minor improvement of depressive symptoms, but

continues to experience active thoughts of suicide, an issue you address through recurrent

risk-assessment and regular completion of a safety contract. Following a particularly

emotional session last week, your client unexpectedly no-shows for the appointment with

you today, despite agreeing to attend the week before. You attempt to reach your client

by phone and text during the hour of the appointment, but you are unable to connect. You

begin worrying about your client’s safety and start thinking about whether you should

intervene by calling on someone to do a safety check. You remember, however, that your

client reported being a “very private person,” and that people "cannot know” about the

therapy.

Based on the information presented, please rate, from 0 (Totally unlikely) to 100

(Totally likely), how likely you would be to conduct a digital welfare check by

accessing your client’s social media profile outside of the therapy session, in order to

obtain more information in order to ensure the client's safety? Please respond 0-100:

_____________

APPENDIX E

General Ethical Principles Questionnaire

Please complete the following questions regarding the vignettes:

1. Regarding Vignette A: Given the descriptions of each of the APA General

Ethical Principles (APA, 2017) listed below, please rate each one according to

how much influence the principle had on your rating of your likelihood to check

your client’s social media profile, in order to obtain more information with

which to assess current suicide risk, as depicted in the first vignette.

Your rating of each principle should be on a scale from 0 (No influence at all) to

100 (Total influence) AND all 5 ratings must TOTAL 100.

 Beneficence and Nonmaleficence (i.e., duty to protect, do good and avoid

harm)

Rating 0 to 100: _____

 Respect for Peoples' Rights and Dignity (i.e., confidentiality, privacy, self-

determination)

Rating 0 to 100: _____

 Fidelity and Responsibility (i.e., clarifying professional role, establishing

trust with the client)

Rating 0 to 100: _____

 Justice (i.e., managing potential biases and maintaining competence)

Rating 0 to 100: _____

 Integrity (i.e., promoting honesty and truthfulness in practice)

Rating 0 to 100: _____

Please check to be sure that all 5 of your ratings TOTAL to 100.

2. Regarding Vignette B: Given the descriptions of each of the APA General

Ethical Principles (APA, 2017) listed below, please rate each one according to

how much influence the principle had on your rating of your likelihood to check

your client’s social media profile, in order to obtain more information in order

to ensure their safety, as depicted in the second vignette.

Your rating of each principle should be on a scale from 0 (No influence at all) to

100 (Total influence) AND all 5 ratings must TOTAL 100.

 Beneficence and Nonmaleficence (i.e., duty to protect, do good and avoid

harm)

Rating 0 to 100: _____

 Respect for Peoples' Rights and Dignity (i.e., confidentiality, privacy, self-

determination)

Rating 0 to 100: _____

 Fidelity and Responsibility (i.e., clarifying professional role, establishing

trust with the client)

Rating 0 to 100: _____

 Justice (i.e., managing potential biases and maintaining competence)

Rating 0 to 100: _____

 Integrity (i.e., promoting honesty and truthfulness in practice)

Rating 0 to 100: _____

Please check to be sure that all 5 of your ratings TOTAL to 100.

APPENDIX F

Vignette Follow-Up Questionnaire

Please complete the two follow-up questions regarding the vignettes below:

1. Would your likelihood rating for Vignette A (regarding using social media

information to contribute to your assessment of suicide risk) have changed if you

had read in the vignette an explicit statement that the client had been informed of

and agreed to your (as the therapist) practice of accessing their social media

profile in situations of possible suicide risk?

Yes: _____ No: _____

If Yes: Why would your likelihood rating have changed?

If Yes: What likelihood rating would you have given (0-100)?: _______

2. Would your likelihood rating for Vignette B (regarding doing a digital welfare

check) have changed if you had read in the vignette an explicit statement that the

client had been informed of and agreed to your (as the therapist) practice of

accessing their social media profile in situations of possible suicide risk?

Yes: _____ No: _____

If Yes: Why would your likelihood rating have changed?

If Yes: What likelihood rating would you have given (0-100)?: _______

APPENDIX G

Therapist Characteristics Questionnaire

ABOUT YOU:

1. Your gender:

Female ________

Male ________

Gender Variant/non-conforming _______

Prefer not to answer _______

2. Your age (in years): _______

3. To what racial group/ethnicity do you most identify?:

American Indian or Alaska Native ________

Asian/Southeast Asia or Far East ________

Asian/Indian Subcontinent ________

Middle Eastern ________

Black or African American ________

Hispanic or Latino ________

Native Hawaiian or Other Pacific Islander ________

White or Caucasian ________

Mixed ________

Other ________

4. Your most advanced educational degree and field of degree:

B.A. ________

B.S. ________

M.A. ________

M.S. ________

Ph.D. ________

Psy.D. ________

Ed.D. ________

Other ________

Field in which you received the above degree:

________________

5. Are you currently practicing as a licensed or certified psychologist?

Yes ________

No ________

5.a. If Yes, for how many years have you been licensed? _________

6. Are you currently being supervised in a doctoral-level psychology training program?

Yes ________

No ________

6.a. If Yes, for how many years have you been in supervision? _______

6.b. If Yes, what year of doctoral-level psychology graduate program are

you in? _______

7. Please indicate the state where your clinical practice (if you are a licensed

psychologist) or doctoral-level training program (if you are a psychologist-in-training) is

located:

_____________

8. Please indicate the approximate percentage of adult clients and child/adolescent clients

in your current caseload. Please be sure that your two responses add up to 100%.

Adult clients: _____%

Child/Adolescent clients: _____%

9. Using a total of 100 "points," please rate, from 0 to 100, how much you draw upon

each of these major theoretical orientations in your conceptualizations of and

interventions with your clients. Please be sure that the total of your responses is 100.

a. Cognitive-Behavioral (e.g. CBT, DBT, REBT)

______________

b. Humanistic-Existential (e.g. Gestalt therapy, Emotion-Focused therapy,

Logotherapy, Person-Centered Therapy, Reality Therapy)

______________

c. Psychoanalytic/Psychodynamic (Classical Psychoanalysis, Jungian Therapy,

Adlerian Psychology, Neo-Freudian, Object Relations)

______________

d. Other (e.g. Systems Theory, Structural Family Therapy, Solution-Focused

Therapy, Motivational Interviewing, Interpersonal Psychotherapy, Feminist

Therapy)

______________

10. Is this statement True or False for you?

For most of my childhood, I was surrounded by and used Internet- and computer-based

tools such as smartphones, e-mail, and social media.

True ________

False ________

11. Please rate how comfortable you currently are with understanding and navigating

modern social media platforms and communications on a scale from 0 (Not at all

comfortable) to 100

(Totally comfortable): ________

12. Please indicate (by an X) all of the social media platforms that you use on a regular

basis. For each platform that you do indicate, please identify how many days per week

you use that platform:

Platform: Days per Week:

Twitter ________ ________

Facebook ________ ________

Instagram ________ ________

Reddit ________ ________

Snapchat ________ ________

LinkedIn ________ ________

WhatsApp ________ ________

Tumblr ________ ________

TikTok ________ ________

Pinterest ________ ________

13. To what degree (from 0 to 100) have you received training (through didactics,

supervision, or consultation) regarding therapist online conduct (e.g., having personal or

professional Facebook accounts, accidentally or intentionally accessing client online

information), where 0 = None at all and 100 = Extensive: _______

14. Do you think your likelihood rating for either vignette was influenced by changes to

the current general practice of psychology in response to the current COVID-19

pandemic?

Yes ______ No ______

If Yes, how?:

15. In the 6 months before the COVID-19 pandemic hit in March 2020, how much of

your therapy practice was conducted in-person vs. via teletherapy (0-100%)? Please be

sure that your two responses add up to 100%

In-person: ________%. Teletherapy: _________%

16. Since March 2020, how much of your therapy practice has been conducted in-person

vs. via teletherapy (0-100%)? Please be sure that your two responses add up to 100%

In-person: ________%. Teletherapy: _________%

APPENDIX H

Listserv Recruitment Sites

APA Divisions

Military Psychology 19

Society for Humanistic Psychology 32

Society of Group Psychology and Group Psychotherapy 49

Society for the Psychology of Women 35

State-specific psychological associations

California Psychological Association

California Psychological Association - Early Career Psychologist

California Psychological Association - Graduate Students

Hawaii Psychological Association

Hawaii Psychological Association - Early Career Psychologist

New York State Psychological Association

New York State Psychological Association - Early Career Psychologist

Oregon Psychological Association

Pennsylvania Psychological Association

 
99 
APPENDIX I 
 
Social Media (Facebook) Recruitment Sites 
 
ACT for ABA Practitioners 
ACT Made Simple - Acceptance & Commitment Therapy for Practitioners 
Addiction Therapists Group 
APA ATI in Research Methods with Diverse Racial & Ethnic Groups Alumni 
APA Division 45 
APA Division 7 - Developmental Psychology 
Asian American Psychology Student Association (AAPSA) 
Association for the Psychoanalysis of Culture and Society 
Attachment-Based Therapists 
Austin Mental Health Professionals 
AZ Mental Health Professionals 
Bay Area MFT/PsyD & PhD Collective 
Become a More Effective Therapist 
California Licensed Psychologists 
California Psychotherapists in Private Practice 
CBT Practitioner Network 
Christian Counselors in Private Practice 
Christian therapists 
Clinicians of Color in Private Practice 
Cognitive Behavior Therapy 
Contextual Behavioral Science (CBS) 
Counselling and Psychotherapy Networking  
Counsellors & Psychotherapists Worldwide 
CSULB Marriage and Family Therapy 
DC Therapist Connect 
Division on South Asian Americans (DoSAA) 
Early Career Feminist Psychologists 
East Texas Therapy Network 
EMDR Therapist Resources 
Emotion-Focused Family Therapy (EFFT) 
Filipino American Mental Health Professionals 
Florida Mental Health Professionals 
Florida Therapist Network (Mental Health Counselors) 
Florida Therapists in Private Practice and Referral Resources 
Greater Houston Mental Health Professionals 
IFS (Internal Family Systems) Community Group 
IPA in Health. International psychoanalytical  
LA Therapists (Psychotherapists, Psychologist, LCSW) 
Latinx Counselors & Therapists 
Latinx Doctoral Psychology Students and Early-Career Psychologists 
Latinx Therapists 
LGBQIA and Trans Affirming Therapists 

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LGBTQ-Affirming Mental Health Resources

The Site for Contemporary Psychoanalysis

Marriage and Family Therapists of Washington State

Marriage and Family Therapists

Melanin & Mental Health Professionals

Mental health professionals

Mental Health Professionals of Fairfield County, CT

MFT & PCC: Dual licensure in California

MFT Guide

MFT Resource Group

Midsouth Therapist Network Page

MilSpouse Network for Mental Health Professionals

Mindfulness Practitioners of Color

Mississippi Mental and Behavioral Health Professionals

MN LGBTQ+ Therapists Network

Montana Mental Health Professionals

Muslim Mental Health Professionals and Students

My Private Practice Collective

DC Therapist Connect

Nevada Association of School Psychologists (NVASP)

North Texas Therapists Network

NYC Area therapists in private practice

Omaha Therapist Network (OTN)

Online Psychologist

Online Therapists of Texas

Orange County Shrinks Clinical Group

Play Therapy and EMDR Therapy Conversations

Professional Mental Health Counselors, Social Workers, & Psychologists

Psychiatry and Clinical Psychology

Psychological scales, tests and researches group

Psychology Workshops and Events

Psychotherapist Training Resource Page

Psychotherapy: Cognitive Behavioral Therapy within an Integrative Approach

Real Therapists Of New York And New Jersey

Resilience Based Psychotherapists - Supporting Families in Tough Times

Respectful Relationships ~ Therapists & Counselors

SD Mental Health Professionals

Self Care for Therapists

South Florida Psychotherapists

The Couples Therapist Couch

The Modern Therapists Group

The Organized Therapist

The Profitable Practice for Healers

The Sandtray Movement

The Testing Psychologist Community

The Trauma Treatment Collective

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Therapist and Educators Market Place Buy/Sell/ Trade

Therapists in Corvallis & Albany

Therapists in Private Practice (TIPP)

Therapists Support LGBTQ in OC

Therapists who ROCK

Therapy in Color Clinicians

Therapist community

Trauma Psychotherapy

Inland Empire Shrinks

Traveling Therapists Jobs Nationwide

Vegan Therapists & Mental Health Professionals

Ventura County Mental Health Professional