E-Health Interventions for Suicide Prevention

Helen Christensen, Philip J. Batterham, and Bridianne O'Dea
Int. J. Environ. Res. Public Health 2014, 11(8), 8193-8212
doi:10.3390/ijerph110808193

Abstract: 

Many people at risk of suicide do not seek help before an attempt, and do not remain connected to health services following an attempt. E-health interventions are now being considered as a means to identify at-risk individuals, offer self-help through web interventions or to deliver proactive interventions in response to individuals’ posts on social media. In this article, we examine research studies which focus on these three aspects of suicide and the internet: the use of online screening for suicide, the effectiveness of e-health interventions aimed to manage suicidal thoughts, and newer studies which aim to proactively intervene when individuals at risk of suicide are identified by their social media postings. We conclude that online screening may have a role, although there is a need for additional robust controlled research to establish whether suicide screening can effectively reduce suicide-related outcomes, and in what settings online screening might be most effective. The effectiveness of Internet interventions may be increased if these interventions are designed to specifically target suicidal thoughts, rather than associated conditions such as depression. The evidence for the use of intervention practices using social media is possible, although validity, feasibility and implementation remains highly uncertain.

The entire research article is here.

When Cupid fires arrows double-blind: implicit informed agreement for online research?

By Anders Sandberg
Practical Ethics
Originally posted on Jul 31, 2014

A while ago Facebook got into the news for experimenting on its subscribers, leading to a fair bit of grumbling. Now the dating site OKCupid has proudly outed itself: We Experiment On Human Beings! Unethical or not?

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The harm angle is more interesting. While Facebook affected the emotions slightly on people who might not have expected emotional manipulation, OKCupid is all about emotions and emotion-laden social interaction. People date because of the site. People have sex because of the site. People marry because of the site. Potentially manipulations could have far more far reaching consequences on OKCupid than on Facebook.

The entire blog post is here.

Who’s Googled whom?

Trainees’ Internet and online social networking experiences, behaviors, and attitudes with clients and supervisors.

By P. Asay and Ashwini Lal
Training and Education in Professional Psychology, Vol 8(2), May 2014, 105-111.
doi: 10.1037/tep0000035

Abstract

The ubiquity of the Internet and online social networking creates rapidly developing opportunities and challenges for psychologists and trainees in the domains of relationships, privacy, and connection. As trainees increasingly are natives of an Internet culture, questions arise about the ways in which developing psychologists may view Internet issues and the guidance they receive from professional psychologists for whom the Internet is a significant cultural shift. A national survey of graduate students (n = 407) assessed student Internet behaviors (e.g., “Googling” clients, online social networking), training about online issues, attitudes toward online social networking and client or supervisor contact via these networks, and fears and comfort about making decisions regarding these networks. The survey also assessed what students reported they would do and what they would think if clients and supervisors contacted them via social networks. Results indicate that most trainees have changed and monitored their online presence since beginning graduate school. A quarter of respondents had “Googled” clients, and almost half had “Googled” supervisors. A small number indicated that both clients and supervisors had reported “Googling” the trainee. Students expressed concerns about making ethical decisions about online social networks. Half reported discussing Internet issues in their graduate training programs, whereas a quarter indicated they had discussed Internet issues at their training sites. Implications for training are discussed, with recommendations of program disclosure of Internet policies to students, discussion of Internet issues before trainee clinical work, role plays of ethical issues, and supervisor-initiated discussions of Internet issues.

The entire article is here.

Seeking and Finding Our Clients on the Internet: Boundary Considerations in Cyberspace

Kolmes, K. & Taube. D. O. (2012). Seeking and Finding Our Clients on the Internet: Boundary 

Considerations in Cyberspace. Professional Psychology: Research and Practice 

Advance online publication. doi: 10.1037/a0029958 

Abstract 

As psychologists and clients increasingly use the Internet for personal and professional activities, they run the risk of having more incidental contacts online. This survey examined the experiences of 227 mental health professionals of various disciplines and training levels about both accidental and intentional experiences encountering client information on the Internet. One hundred and nine participants intentionally sought information about current clients in noncrisis situations, and 63 participants accidentally discovered client information on the Internet. This paper explores how clinicians responded to these encounters and clinicians’ beliefs about how they influenced treatment. Recommendations are made for how mental health professionals may begin to address such issues in the clinical relationship. 

The entire article is here.

How we were fooled into thinking that sexual predators lurk everywhere

By Dana Boyd
From It’s Complicated: The Social Lives of Networked Teens
Published by Yale University Press

Here are two excerpts:

As moral panics about child safety take hold, politicians feel that they should take action—or at least capitalize on the appearance of doing so. They regularly campaign over safety issues and implement or expand laws targeted at curtailing the freedoms of minors. In the 1980s and 1990s, this included curfew laws, anti-loitering laws, and truancy laws. To expunge teens from public places, cities and towns limited where, when, and for how long teens could gather or hang out in public places. Many believed that curfew laws would combat crime; a 1997 survey of US mayors found that 88 percent believed that youth curfews reduced crime. It did not. As researchers began to examine the effects of these laws, they found that there was no correlation between curfews and youth crime. After analyzing the data, sociologist Michael Males concluded that authority figures use curfews more as a symbol of social control than an actual crime deterrent.

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Through social media, teenagers have created digital streets that help define the networked publics in which they gather. In an effort to address online safety concerns, most adults respond by trying to quarantine youth from adults, limit teens’ engagement online, or track teens’ every move. Rhetoric surrounding online predation is used to drum up fear and justify isolation. But neither restrictions nor either adult or institutional surveillance will help those who are seriously struggling.

The entire chapter is here.

Thanks to Gary Schoener for this information.

Online Medical Professionalism: Patient and Public Relationships

Policy Statement From the American College of Physicians and the Federation of State Medical Boards

By Jeanne M. Farnan, Lois Snyder Sulmasy, and others
Ann Intern Med. 2013;158(8):620-627. doi:10.7326/0003-4819-158-8-201304160-00100

Abstract

User-created content and communications on Web-based applications, such as networking sites, media sharing sites, or blog platforms, have dramatically increased in popularity over the past several years, but there has been little policy or guidance on the best practices to inform standards for the professional conduct of physicians in the digital environment. Areas of specific concern include the use of such media for nonclinical purposes, implications for confidentiality, the use of social media in patient education, and how all of this affects the public's trust in physicians as patient–physician interactions extend into the digital environment. Opportunities afforded by online applications represent a new frontier in medicine as physicians and patients become more connected. This position paper from the American College of Physicians and the Federation of State Medical Boards examines and provides recommendations about the influence of social media on the patient–physician relationship, the role of these media in public perception of physician behaviors, and strategies for physician–physician communication that preserve confidentiality while best using these technologies.

The entire policy statement is here.

Digital and Social Media for Psychologist: Current Issues and Ethical Dilemmas

By Keely Kolmes, PsyD

Psychologists, whether they are in independent practice, working in an agency setting, or are teaching and supervision, are struggling more and more with issues related to their own, their trainees', and their clients' online access and availability.  Zur and Donner (2009) wrote about the accessibility of online information.  the compared unintentional vs. intentional disclosures clinicians may make during the psychotherapy hour and then compared these with the unintentional disclosures that psychotherapists might make available on the Internet when clients seek out information about providers.  They noted that the motivations could range from mild curiosity to criminal stalking, and they encouraged clinicians to maintain awareness of what information is made available about them.

The entire article is here.

Authors call for 'digital bill of rights'

BBC News
Originally published December 10, 2013

Hundreds of authors from around the world have written to the United Nations urging it to create an international bill of digital rights.

More than 500 writers signed the open letter condemning the scale of state surveillance following recent leaks about UK and US Government activities.

Ian McEwan, Tom Stoppard and Will Self are among the British signatories.

"To maintain any validity, our democratic rights must apply in virtual as in real space," the letter says.

The entire story is here.

Internet forums can have a positive influence on self-harmers, say researchers

By Jochan Embley
The Independent
Originally published October 31, 2013

Internet forums and chatrooms can have a positive influence on young people at risk from self-harm or suicide, researchers have found.

The review, which comes from researchers at Oxford University, does admit that there are also negative, potentially dangerous aspects to forums, however.

The entire story is here.

48 countries join forces against online child abuse

By Associated Press
Originally Published: December 5


Forty-eight countries united Wednesday in a global alliance to fight child sexual abuse online, a cross-border crime that experts say is increasing at alarming rates.

By conservative estimates, 1 million photographs of child pornography are on the Internet, with an additional 50,000 being posted every year, said Cecilia Malmstrom, the European Union’s commissioner for home affairs who was one of sponsors of the conference in Brussels.


“Behind each of these images there is an abused child, an exploited and helpless victim,” Malmstrom said at a news conference. “And every time someone looks at these pictures, that child is exploited and violated again and again and again.”

The alliance will focus on identifying and helping victims, prosecuting offenders, increasing public awareness and reducing the availability of child pornography online, according to a joint declaration.

The entire story is here.

Clinical Challenges in the Internet Era

By Glen O. Gabbard, M.D.
American Journal of Psychiatry

Here's a central passage from the initial case presentation:

[begin excerpt]

Much to the treatment team's surprise, within a week of Mr. R's first outpatient appointment, Mrs. R had begun posting disparaging comments on various web sites about the quality of her son's care, specifically naming the treating resident.

The comments described the treating resident as well as other members of the treatment team in derogatory terms. 

In addition, Mrs. R made comments that were vehemently antipsychiatry, including a statement that psychiatrists collude with pharmaceutical companies to generate profit rather than treat illness.

She posted multiple comments in the days following certain clinic visits; the comments could be found easily by anyone who did a Google search using the treating resident's name.

The comments initially appeared on both a personal blog and a highly popular web site, later cropping up also on web sites that serve as general forums for consumer dissatisfaction and on news outlets as user-generated content.

(cut) 

Two main concerns arose from the ensuing dialogue. Foremost was the potential for the mother's online comments to undermine Mr. R's care. For example, awareness of his mother's comments could exacerbate Mr. R's paranoia, leading to a disruption in his trusting relationship with the resident and a possible interference with his adherence to treatment. Moreover, the tone of the mother's comments suggested a fundamental disagreement with the treatment team's approach to her son's care, one that could potentially lead to an impasse. In the absence of a satisfactory working relationship with Mr. R's mother, the team would need to consider discharging him with a referral to another provider. Were they to do so, however, apart from feeling disappointed at not being able to continue providing Mr. R's care, the team would risk appearing either to be punishing him for his mother's actions or abandoning him for no clear reason. Either interpretation might fuel the paranoid perceptions he had regarding mental health care providers.

The second concern was that the mother's comments could damage the reputation of the treating resident. The resident initially did not think to be worried about his reputation, since he felt confident that he was well regarded by those who knew him and had observed his work with patients. Once this concern was raised, however, the resident thought of the potential impact the mother's public comments might have if he sought employment or further training outside his current institution. Given the fact that there is only limited public commentary concerning residents, a few negative Internet postings might adversely affect the opinions of potential patients, peers, or employers. Hence, the situation presented a quandary regarding how to respond to the comments posted online by Mr. R's mother while trying to avoid both potential harm to the patient and potential harm to the resident.

 (cut)

 Discussion: 

When I was asked to consult on this case, I felt a good deal of empathy for the resident.

Here he was, delivering good psychiatric care to a young man with severe illness, but receiving criticism rather than appreciation from the family. 

I recognized that there is now a public exposure inherent in psychiatric practice that can be daunting even to experienced clinicians but may be especially painful to vulnerable residents who are striving to become competent psychiatrists. 

[end excerpt]

Here's how the article ends:  

What can we do as a profession in the face of these challenges? The proliferation of Facebook, Internet forums, Twitter, blogs, and chat rooms is a juggernaut that cannot be stopped. We must live with these new intrusions into our professional lives and develop creative solutions. Institutions can develop policies so that ad hoc groups do not have to be assembled whenever delicate situations with potential liability arise.

Psychiatrists and other mental health professionals can do periodic Internet searches of themselves to keep abreast of any personal or professional information about them that may have implications for their reputation. In some cases, web site administrators may be contacted who will remove what is posted. Those who use social networking sites like Facebook should probably use all available privacy settings so that personal information about them is not available to the public.

The education of psychiatric residents and other mental health professionals should include discussions of common challenges that occur in the Internet era so that clinicians have some preparation for dealing with them when they emerge. Finally, guidelines regarding how to continue the treatment and how to respond to the attacks should be developed. Academic psychiatry has a long tradition of establishing protocols to deal constructively with difficult events in the trainee's life, such as patient suicide or assault. Similar forms of support and assistance can be brought to bear to assist with challenges stemming from the Internet."

 Thanks to Ken Pope for this information.

 The entire article is here.

Membership is needed to acces this information.

Gabbard GO. Clinical challenges in the internet era. Am J Psychiatry. 2012

May;169(5):460-3. PubMed PMID: 22549206.

People May Lie More Often in Emails, Instant Messages

By Randy Dotinga
MedicineNet.com

New research suggests that people are more likely to lie to strangers when they're communicating via email or instant messages rather than when they are talking face-to-face.

"It's not news that we lie. What's new is that we lie even more online," said study author Mattitiyahu Zimbler, a graduate student and senior researcher at the University of Massachusetts-Amherst.

In the study, the researchers recruited 220 undergraduate students and told them to converse with people of the same gender for 15 minutes, via email, instant message or face-to-face.

The participants introduced themselves to each other and researchers recorded their conversations. Then the researchers asked the participants to look at transcripts and note when they lied.

The researchers found that the participants averaged about 1.5 lies during each 15-minute period.

The lies tended to be minor, often matters of omission. One said, "I am short, credit-wise," instead of acknowledging the failing of classes. Some said they were doing "well" or "good" when that wasn't actually the case; one said "I wanted to be a waitress," when that wasn't true.

The entire article can be found here.

When Your Therapist Is Only a Click Away

By Jan Hoffman
The New York Times

THE event reminder on Melissa Weinblatt’s iPhone buzzed: 15 minutes till her shrink appointment.

She mixed herself a mojito, added a sprig of mint, put on her sunglasses and headed outside to her friend’s pool. Settling into a lounge chair, she tapped the Skype app on her phone. Hundreds of miles away, her face popped up on her therapist’s computer monitor; he smiled back on her phone’s screen.

She took a sip of her cocktail. The session began.

Ms. Weinblatt, a 30-year-old high school teacher in Oregon, used to be in treatment the conventional way — with face-to-face office appointments. Now, with her new doctor, she said: “I can have a Skype therapy session with my morning coffee or before a night on the town with the girls. I can take a break from shopping for a session. I took my doctor with me through three states this summer!”

And, she added, “I even e-mailed him that I was panicked about a first date, and he wrote back and said we could do a 20-minute mini-session.”

Since telepsychiatry was introduced decades ago, video conferencing has been an increasingly accepted way to reach patients in hospitals, prisons, veterans’ health care facilities and rural clinics — all supervised sites.

But today Skype, and encrypted digital software through third-party sites like CaliforniaLiveVisit.com, have made online private practice accessible for a broader swath of patients, including those who shun office treatment or who simply like the convenience of therapy on the fly.

One third-party online therapy site, Breakthrough.com, said it has signed up 900 psychiatrists, psychologists, counselors and coaches in just two years. Another indication that online treatment is migrating into mainstream sensibility: “Web Therapy,” the Lisa Kudrow comedy that started online and pokes fun at three-minute webcam therapy sessions, moved to cable (Showtime) this summer.

“In three years, this will take off like a rocket,” said Eric A. Harris, a lawyer and psychologist who consults with the American Psychological Association Insurance Trust. “Everyone will have real-time audiovisual availability. There will be a group of true believers who will think that being in a room with a client is special and you can’t replicate that by remote involvement. But a lot of people, especially younger clinicians, will feel there is no basis for thinking this. Still, appropriate professional standards will have to be followed.”

The pragmatic benefits are obvious. “No parking necessary!” touts one online therapist. Some therapists charge less for sessions since they, too, can do it from home, saving on gas and office rent. Blizzards, broken legs and business trips no longer cancel appointments. The anxiety of shrink-less August could be, dare one say ... curable?

Ms. Weinblatt came to the approach through geographical necessity. When her therapist moved, she was apprehensive about transferring to the other psychologist in her small town, who would certainly know her prominent ex-boyfriend. So her therapist referred her to another doctor, whose practice was a day’s drive away. But he was willing to use Skype with long-distance patients. She was game.

Now she prefers these sessions to the old-fashioned kind.

But does knowing that your therapist is just a phone tap or mouse click away create a 21st-century version of shrink-neediness?

The entire story can be read here.

Harvard Researchers Accused of Breaching Students' Privacy

Social-network project shows promise and peril of doing social science online

By Marc Parry
Chronicle of Higher Education

In 2006, Harvard sociologists struck a mother lode of social-science data, offering a new way to answer big questions about how race and cultural tastes affect relationships.

The source: some 1,700 Facebook profiles, downloaded from an entire class of students at an "anonymous" university, that could reveal how friendships and interests evolve over time.

It was the kind of collection that hundreds of scholars would find interesting. And in 2008, the Harvard team began to realize that potential by publicly releasing part of its archive.

But today the data-sharing venture has collapsed. The Facebook archive is more like plutonium than gold—its contents yanked offline, its future release uncertain, its creators scolded by some scholars for downloading the profiles without students' knowledge and for failing to protect their privacy. Those students have been identified as Harvard College's Class of 2009.

The story of that collapse shines a light on emerging ethical challenges faced by scholars researching social networks and other online environments.

The Harvard sociologists argue that the data pulled from students' Facebook profiles could lead to great scientific benefits, and that substantial efforts have been made to protect the students. Jason Kaufman, the project's principal investigator and a research fellow at Harvard's Berkman Center for Internet & Society, points out that data were redacted to minimize the risk of identification. No student seems to have suffered any harm. Mr. Kaufman accuses his critics of acting like "academic paparazzi."

Adding to the complications, researchers like Mr. Kaufman are being asked to safeguard privacy in an era when grant-making agencies increasingly request that data be shared—as the National Science Foundation did as a condition for backing Harvard's Facebook study.

The Facebook project began to unravel in 2008, when a privacy scholar at the University of Wisconsin at Milwaukee, Michael Zimmer, showed that the "anonymous" data of Mr. Kaufman and his colleagues could be cracked to identify the source as Harvard undergraduates.

The entire story can be read here.

The Internet's Ethical Challenges

A common theme on this blog is the nexus of psychology and ethics on the internet.  The capacity to communicate, interact and build relationships at a distance is becoming increasingly easy and affordable.  From a number of discussions with college students, some individuals actually prefer texting and skyping to outdated emailing and talking on the phone.

Psychologists will continue to venture into telepsychology and building relationships over the internet.  As clinical practice continues to move into this brave new world, psychologists need to consider the ethical implications of new technologies with their work as well as their personal lives.

Sara Martin from the APA's Monitor wrote a story entitled The Internet's Ethical Challenges.  A portion of the article is listed below.  The information just begins to scratch the surface of ethical issues related to a psychologist's presence on the internet.

-----------------------------

Should you Google your clients?

Should you ‘friend’ a student on Facebook?

APA’s Ethics Director Stephen Behnke answers those questions and more.

No form of client communication is 100 percent guaranteed to be private. Conversations can be overheard, e-mails can be sent to the wrong recipients and phone conversation can be listened to by others.

But in today’s age of e-mail, Facebook, Twitter and other social media, psychologists have to be more aware than ever of the ethical pitfalls they can fall into by using these types of communication.

“It’s easy not to be fully mindful about the possibility of disclosure with these communications because we use these technologies so often in our social lives,” says Stephen Behnke, PhD, JD, director of APA’s Ethics Office. “It’s something that we haven’t gotten into the habit of thinking about.”


Stephen Benhke


The Monitor sat down with Behnke to discuss the ethical aspects of the Internet for psychology practitioners and how to think about them.

Does the APA Ethics Code guide practitioners on social media?

Yes. The current Ethics Code was drafted between 1997 and 2002. While it doesn’t use the terms “social media,” “Google” or “Facebook,” the code is very clear that it applies to all psychologists’ professional activities and to electronic communication, which of course social media is.



As we look at the Ethics Code, the sections that are particularly relevant to social media are on privacy and confidentiality, multiple relationships and the section on therapy. The Ethics Code does not prohibit all social relationships, but it does call on psychologists to ask, “How does this particular relationship fit with the treatment relationship?”

Is the APA Ethics Office seeing any particular problems in the use of social media?



Everyone is communicating with these new technologies, but our ethical obligation is to be thoughtful about how the Ethics Code applies to these communications and how the laws and regulations apply.

For example, if you are communicating with your client via e-mail or text messaging, those communications might be considered part of your client’s record. Also, you want to consider who else might have access to the communication, something the client him- or herself may not be fully mindful of. When you communicate with clients, the communication may be kept on a server so anyone with access to that server may have access to your communications. Confidentiality should be front and center in your thinking.



Also, consider the form of communication you are using, given the kind of treatment you are providing. For example, there are two very different scenarios from a clinical perspective: In one scenario, you’ve been working with a client face-to-face and you know the client’s clinical issues. Then the client goes away on vacation and you have one or two phone sessions, or a session or two on Skype. A very different scenario is that the psychologist treats a client online, a client he or she has never met or seen. In this case, the psychologist has to be very mindful of the kind of treatment he or she can provide. What sorts of issues are appropriate to treat in that manner? How do the relevant jurisdiction’s laws and regulations apply to the work you are doing?

That’s an example of how the technology is out in front of us. We have this wonderful new technology that allows us to offer services to folks who may never have had access to a psychologist. At the same time, the ethical, legal and regulatory infrastructure to support the technology is not yet in place. A good deal of thought and care must go into how we use the technology, given how it may affect our clients and what it means for our professional lives.



APA needs to be involved in developing that ethical, legal and regulatory infrastructure and needs to be front and center on this.

What do you want members to know about using Facebook?

People are generally aware that what they put on their Facebook pages may be publicly accessible. Even with privacy settings, there are ways that people can get access to your information.



My recommendation is to educate yourself about privacy settings and how you can make your page as private as you want it to be. Also, educate yourself about how the technology works and be mindful of the information you make available about yourself. Historically, psychology has talked a lot about the clinical implications of self-disclosure, but this is several orders of magnitude greater, because now anyone sitting in their home or library with access to a terminal can find out an enormous amount of information about you.

Facebook is a wonderful way to social network, to be part of a community. And of course psychologists are going to use this, as is every segment of the population. But psychologists have special ethical issues they need to think through to determine how this technology is going to affect their work.