Graduate Student Journal of Psychology 2014, Vol. 15 Copyright 2014 by the Department of Counseling and Clinical Psychology Teachers College, Columbia University 81 Psychosocial Media: An Argument for the Utilization of Online Social Networks as Clinical Adjuncts in Psychotherapy Jett H. Stone Teachers College, Columbia University This paper argues for the utilization of online social networks (OSNs) as clinical adjuncts in psychotherapy with ad- olescents and young adults. While privacy and ethics are critical issues in psychotherapy, these concerns should not overshadow the various ways that an OSN adjunct may enhance the therapeutic alliance and advance psychothera- peutic practice. The argument asserts that a joint exploration of OSN profile pages – a mental health professional in conjunction with an approving client – may provide clinically relevant details, and a more comprehensive con- ceptualization of emotional and interpersonal functioning. The specific content of OSN disclosures are discussed, referencing current cyberpsychology and communications research. In addition, the procedural question of when, in a therapeutic relationship, it may be appropriate to initiate a psychosocial media approach, is also addressed. Comparisons are then made between OSN integration and previous incorporation of personal images and visual expression in psychotherapy. The penultimate section details how OSNs may be viewed from a narrative psycho- logical standpoint, and the numerous ways these new social tools can be interpreted or understood within various other psychological frameworks. Lastly, this paper cites the general effectiveness of other technological adjuncts in psychotherapy, and offers final recommendations for the potential marriage of social media and psychotherapy. The speed, ease, and seeming frivolity of so- cial media may seem antithetical to the core values of the sensitive and difficult process of psychother- apy. Popular social media sites or online social net- works (OSNs) such as Facebook and Twitter, are profit-seeking companies racing to claim stake in the future, and are built on the premise that consumers will publicly share personal information. Conversely, psychotherapy – ideally practiced – is a healing pro- fession that holds client confidentiality and privacy sacred, and only advances at the irregular speed of ev- idenced-based practice. While these distinctions may ring true, they overlook the potential role of OSNs as valuable clinical adjuncts in the therapeutic process. One of the challenges in psychotherapy is fine-tuning treatments and clinical strategies to match the needs of an individual. This paper asserts that social media profiles – when investigated alongside adolescents or young adults – can be powerful tools to tune into and ultimately treat present-day psychological issues. Because so much personal information is shared in therapy, authorized access to OSN profiles may be an important added ingredient for a complete 21st century client conceptualization; especially for the youth and young adults whose online social tools are ingrained into their daily lives. The cultural influence of OSNs is evidenced by the statistic that over 80 percent of teens use OSNs, and 92 percent of fe- males between the ages of 14-17 use an OSN site (Brenner, 2012). Social media adjuncts could poten- tially be expanded to adult populations as well. In fact, adults over the age of 18 are increasingly turning to OSNs, despite using them in smaller numbers: of adults who are online, 67 percent use OSNs (Bren- ner, 2013). There has been recent research look- ing into how adults use dating sites to find poten- tial mates (e.g. Finkel et al., 2012), and how online support groups can impact-health related outcomes (e.g. Rains & Young, 2009). In addition, there are a growing number of older adults utilizing these social tools. Thirty-four percent of Internet users 65 and older use OSNs (Zickuhr & Madden, 2012). None- theless, it seems useful to begin adapting OSNs as a clinical adjunct with teens and young adults who are in a critical maturation stage and are general- ly more vulnerable to dangerous online behavior. Potentially maladaptive social networking be- haviors, as well as more incidental status updates or postings, may be best discussed in therapy for teens and young adults, not only because clinicians possess the training to intervene appropriately during inter- personal dilemmas, but also because psychotherapy is inherently a venue for disclosure. In a clinical report released by the American Academy of Pediatrics, the authors stressed that pediatricians are in a unique po- Correspondence concerning this article should be ad- dressed to Jett Stone, 166 West 72nd Street #10C, New York, NY 10023. Email: jettstone@gmail.com. Graduate Student Journal of Psychology 2014, Vol. 15 Copyright 2014 by the Department of Counseling and Clinical Psychology Teachers College, Columbia University 82 STONE sition to educate families about the “complexities of the digital world” and cited social and health issues that online youth experience, such as cyberbullying and “Facebook depression” (O’Keeffe & Clarke-Pe- terson, 2011, p. 803). The authors define Facebook depression as when preteens and teens spend inordi- nate amounts of time on Facebook and, as a result, demonstrate “classic symptoms of depression” (p. 802). This argument for an authoritative intervention holds true perhaps even more so for child psycholo- gists and other mental health professionals whose do- main it is to have a strong grasp of the psychological fitness of youth. In short, a mental health profession- al should be adept at entering into this social domain when called upon or when deemed necessary. How- ever, it is impossible to ignore the tensions and ethical issues in this union of new media and psychotherapy. Ethical Concerns and Other Considerations Many psychotherapists are wary of OSN use from a personal and professional level. Understandably so, as the lines of privacy – determining what is public versus private on the Internet – have become increas- ingly blurred. To ease this uncertainty, a growing body of literature has addressed issues of ethics and privacy as they relate to OSNs and mental health care (Taylor, McMinn, Bufford, & Chang, 2010; Fogel, & Nehmad, 2009; Debatin, Lovejoy, Horn, & Hughes, 2009). In order to protect clinicians and their clients from inappropriate self-disclosures, clinicians are generally discouraged from following or befriending clients or potential clients on OSNs such as Face- book or Twitter (Van Allen & Roberts, 2011). The concern is that these digital “friendships” will create a slippery slope-type cascade into a breach of confi- dentiality and/or privacy (Gutheil & Simon, 2005). In their paper, “Critical Incidents in the Marriage of Psychology and Technology: A Discussion of Potential Ethical Issues in Practice, Education, and Policy” authors Van Allen and Roberts (2011) refer to a metaphor previously used by Maheu (2010) that describes therapists’ utilization of OSNs as similar to drivers handling shiny new sports cars on bumpy, old roads. Naturally, the sports car signifies social media, and the dirt road signifies psychotherapy. Van Allen & Roberts’ (2011) argument is that clinicians have the tools to be innovative, but lack the “current infrastructure” to support the testing of these tools without “considerable risk” (p. 434). While the au- thors never explicitly refer to the potential of using OSNs as adjuncts in therapeutic practice, they assert that current technologies bring about significant risk, and it still remains unclear how these concerns could be better addressed (p. 438). However, it must be made clear that utilizing OSNs as an adjunct would be entirely distinct from befriending or following a client, as the therapist would not engage in any in- terpersonal OSN communication with the client. While there remain unresolved issues, many therapists and institutions have been creating so- cial media policies, and there have indeed been sig- nificant steps forward in creating more widespread recommendations and guidelines for appropriate use (Myers, Endres, Ruddy, & Zelikovsky, 2012); Jent et al., 2011). Regardless, privacy and ethical guidelines are critical issues when discussing the integration of social media and psychotherapy. Yet the functional fixedness of OSNs as inhibiting the therapeutic al- liance overlooks their potential as clinical adjuncts in enhancing the therapeutic alliance and advancing psychotherapeutic practice. However a purely tech- nological, distant and asynchronous level of therapy communication may not work well. A recent Austra- lian study of individuals age 18-80 found that close to 77 percent of people prefer face-to-face therapy rather than therapy by electronic means. The authors defined electronic as “Internet-based mental health assistance with or without support [i.e., communi- cation with a therapist via email, instant messaging, web-cam or Skype])” (Klein & Cook, 2010, p. 29). As Clough & Casey (2011) noted in a review of techno- logical adjuncts in psychotherapy, a major goal has been to focus on ways that technology can “replace or duplicate face-to-face therapy” (Clough & Ca- sey, 2011, p. 280). Therefore this paper proposes a more transparent, face-to-face application of OSNs in therapy that counters the commonly held notion of OSNs as purely fodder for social academic re- search, self-promotion, or personal communication. Based on a PsychInfo search using the search terms “online social network,” “social media,” paired 83 PSYCHOSOCIAL MEDIA with “adjunct” and “psychotherapy” there has been no available research to-date exploring how OSNs can serve as therapeutic instruments. Yet a history of social science literature, along with a boom in cyberpsychol- ogy and social networking research, indicates that there may be a place for such an innovative intervention. With the explicit, endorsed permission of cli- ent or guardian (depending on the client’s age), so- cial media access may provide a more comprehen- sive case conceptualization. It would be revealing to walk through an individual’s Facebook or Twitter profile – alongside a client – as a way of stepping inside their interpersonal world. Clinicians would address or interpret online self-presentations in-per- son as they would for any verbal or nonverbal face- to-face disclosure, but these online disclosures may provide access to more elusive clinical content not typically shared in session. This side-by-side OSN exploration would potentially allow for a fairer, more mutual interpretation of social activity rather than what often occurs asynchronously and from afar between Facebook friends or Twitter followers. An OSN adjunct would naturally require Inter- net service in a therapist’s office, and also necessitate that a client actively use OSNs. This then raises the question of whom – therapist or client – would pro- vide the computer, mobile device or tablet in therapy sessions. While the therapist could bear the burden of providing the media, the client may feel more of a sense of control over their privacy if they use their own technology. Taking the initiative and bringing in their own media would grant the opportunity to pre- pare an OSN profile prior to a therapy session, in order to avoid stumbling upon uncomfortable pho- tos, messages or postings. While the therapist may not explicitly request that a client alter, include, or ex- clude elements of their profile prior to arriving in the office, it is likely that a client will feel inclined to do so without prompt. Surely, allowing this ability to cu- rate a personal profile leaves the clinician with a more restrained version of a client’s OSN presentation. Nonetheless, safeguarding OSN activity outweighs the rupture in therapeutic alliance that may arise from discovering social content that is embarrassing, eas- ily misconstrued or irrelevant to psychotherapy. As the alliance develops over time, perhaps clients will grow more open to revealing aspects of their online lives. Additionally, it seems necessary to remind cli- ents to disable any instant messaging preferences (i.e. Facebook chat) so as not to be disrupted by incom- ing messages from followers or friends in session. While these are suggestions, the therapist and client, based on their relationship, should mutually decide how to logistically and fairly incorporate OSNs into session to facilitate positive psychological outcomes. Content of OSN Disclosures Integrating OSN into therapy sessions as- sumes that online disclosures provide clinically significant content. Recent research indicates that clients do indeed disclose clinically relevant infor- mation online, and may also be receptive to the use of technology in therapy sessions. An indi- vidual’s thoughts, experiences, and emotions are quite often found across the web, from blogs and OSNs to dating websites (Joinson & Paine, 2007). One study, using a sample size of 400 (aged 17- 61) randomly selected, accessible, personal profiles in Canada, developed a scoring tool that assessed the content of Facebook disclosures. They recorded ev- erything from birthdate, ability to message, phone numbers, content of profile photo and educational information to favorite quotes, music, interests, po- litical and religious views. They found that subjects displayed approximately 25 percent of possible infor- mation for others to view on their Facebook profiles (Nosko, Wood, & Molema, 2010). The authors also discovered that there is often “highly personal, sen- sitive and potentially stigmatizing information” on Facebook (p. 416). The authors define highly person- al as “details that could be used to locate or identify an individual, and could be used to threaten or harm another” such as email address, employer and job po- sition (p. 410). Nosko, Wood, & Molema (2010) also define stigmatizing as “sensitive personal information that could result in stigmatization within society” such as religious views, political views, birth year, sexual orientation, about me sections, and photos (p. 410). Such studies looking at online disclosure patterns do not necessarily reveal the whole story of how dis- closure operates on OSNs. This is because users, over 84 time, become more aware of how they can alter their default privacy settings, as was shown in one longitudi- nal study of 5,076 Facebook users at Carnegie Mellon University (Stutzman, Gross, & Acquisti, 2013). Many OSN disclosures – perhaps the most highly emotion- al, personal and therefore pertinent to mental health practitioners – are shared privately or shared only among a limited set of friends or followers, especially with the advent of more advanced privacy settings. Therefore, a large portion of salient OSN activity is inaccessible to researchers working only with public data. These disclosures add another layer to Nosko, Wood, & Molemas’ (2010) operational definition of highly personal and stigmatizing. Given their sensi- tive content, these more behind-closed-doors social interactions may be useful to address in-person, in a private therapeutic environment. Online disclosures may be especially prevalent in adolescents and young teens that use OSNs obsessively or even just frequent- ly. Research indicates that the younger the age, the more personal information is likely to be shared on Facebook profiles (Nosko, Wood, & Molema, 2010). There has also been evidence to support the idea that online self-disclosure is used to rehearse offline disclosure in pre-adolescence and adolescence, espe- cially for boys (Valkenburg, Sumter, & Peter, 2011). This implies that online disclosures may be highly reflective of offline behaviors that a therapist might otherwise not have the opportunity to witness or un- derstand given limited client contact. Or, perhaps a therapist would be able to corroborate online behav- iors with in face-to-face behaviors and thus come to a more confident, complete conceptualization of the client. Other preliminary research indicates that OSNs such as Facebook contain useful clinical information. One study looked at publicly accessible college student Facebook status updates, and used DSM cri- teria to determine whether these disclosures showed signs of depressive symptoms or major depressive episodes (Moreno, Egan, & Brockman, 2011). From the 200 Facebook pages, they found evidence to sup- port the notion that students do display symptoms of depression on their profiles. Twenty-five percent of the studied Facebook profiles displayed DSM cri- teria for depressive symptoms, while 2.5 percent met criteria for a major depressive episode. Additionally, Moreno, Egan, & Brockman (2011) conclude that those who receive online reinforcement from friends are more likely to be public in expressing their symp- toms. Despite the stigmas associated with mental health disclosures, Facebook appears to be a safe place for many young adults to disclose personal de- tails because of the support of their social networks (Moreno, Egan, & Brockman, 2011). Other research shows that increases in depression may be a direct result of negative social media interactions, and that OSN activity is a medium where psychological prob- lems are apparent in dysfunctional interpersonal in- teractions (Feinstein, Bhatia, Hershenberg, & Davilia, 2012). Another study found that Problematic Inter- net Use, defined as online behavior that negatively impacts social and emotional functioning, is pres- ent in about four percent of high school students in the U.S., and is associated with levels of depression, substance use, and aggressive behaviors (Liu, Desai, Krishnan-Sarin, Cavallo, & Potenza, 2011). It is often considered symptomatic of an impulse control disor- der (Shapira et al., 2003). Other, potentially more dan- gerous, behaviors such as cyberbullying, or Internet aggression, have also increased in prominence (e.g. Hinduja & Patchin, 2008; Ybarra & Mitchell, 2004). Researchers have begun to compare cyberbul- lying to more traditional bullying. One study with adolescents found that cyberbullying increases with age and amount of time spent using the Internet (Walrave & Wannes, 2009). Therefore if a clinician were to incorporate OSNs into their sessions with adolescents and young adults active on OSNs, the topic of cyberbullying – as victim or perpetrator – may arise. Recent research indicates that students differentiate between offline and online bullying: in online environments they make less of a distinc- tion between bully and victim and differentiate be- tween the specific modes of bullying, i.e. messages or pictures (Law, Shapka, Hymel, Olson, & Water- house, 2012). Since they make such distinctions, it is therefore important that clinicians have at least a basic understanding of how adolescents and young adults interpret cyberbullying, as well as an under- standing of the various working mechanisms of OSNs. Such an understanding on the part of the therapist would also aid in helping youth explore STONE 85 more adaptive utilizations of these popular tools. In general, psychotherapy is a revealing pro- cess. Psychotherapists are privileged to have unique access to the “inner, private life” of individuals (Shedler, 2006, p. 44). Social media offers just one more path to a person’s private, subjective world. A psychosocial media approach may be one means of exploring sources of suffering. Complicating matters, however, is the fact that this inner, private life is often on display publicly in cryptic, maladap- tive or more selected, adaptive self-presentations. Some research has found that people make more intimate self-disclosures in computer-mediated communication as opposed to face-to-face commu- nication (Tidwell & Walther, 2002). Other research, including a systematic review of 15 studies com- paring online and offline self-disclosures, indicates that disclosure of personal information online is not necessarily greater than it is in offline environ- ments. Rather the mode of communication, the re- lationship between communicators, and the context of the online interactions seem to better moderate the degree of disclosure (Nguyen, Sun, & Camp- bell, 2012). Another group of researchers, after a review of the existing articles on psychological fac- tors contributing to Facebook usage, propose a mod- el that focuses on two personality traits as motiva- tion for using Facebook – the need to belong and need for self-presentation (Nadkarni & Hofmann, 2012). Disclosing online (versus offline) perhaps more easily satisfies these two personality traits. One study (Suler, 2004) examined the Internet’s “disinhibition effect,” whereby people are more likely to self-disclose online, and appear uninhibited rela- tive to their offline selves. This effect describes two different forms of inhibition found online: benign in- hibition and toxic inhibition. Suler defines the benign version as “a process of working through – an at- tempt to better understand and develop oneself, to re- solve interpersonal and intrapsychic problems or ex- plore new dimensions to ones identity” (p. 184). Suler differentiates this from toxic inhibition or a “blind catharsis, a fruitless repetition compulsion or acting out of pathological needs without any beneficial psy- chology change” (p. 184). These two theories may be helpful in not only in interpreting OSN profiles, but also in understanding the recent rise of popular mobile applications such as Snapchat that allow users to send fleeting, risqué photo and video messages to each other. These Snapchats disappear from a recip- ient’s phone after only a few moments, encouraging users to share pornographic content. While a clinician should never have access to such intimate social con- tent, these examples illustrate uninhibited behavior and the willingness to share or perhaps over-share very personal information in new media environments. While the continuum between Suler’s notion of benign and toxic inhibition may be difficult to deter- mine just yet, in future decades more trained mental health professionals will be likely confronted with so- cial media-related issues. Thus, it is important for them to make sense of – but not overly interpret – the many emotions, personalities, unconscious drives and cogni- tions behind these OSN presentations and behaviors. Shame and Timing of a Psychosocial Media Adjunct Another major concern may be that OSN ac- cess engenders feelings of client shame. One criti- cism may be that social media access disrupts the natural unfolding of disclosure, or induces shame before the therapeutic alliance has been established. Because these two points are important to consider, the timing of a psychosocial media intervention may play a vital role in its effectiveness. In one study of adults undergoing face-to-face psychotherapy, initial disclosures generated shame and anticipatory anxiety, but eventually, over time, produced feelings of safety, pride and authenticity (Farber, Berano, & Capobian- co, 2004). Farber and colleagues’ multi-method study further found that disclosure can provide a sense of relief, and that keeping secrets inhibits the process of therapy. Participants expressed a desire for therapists to pursue their secrets more actively by answering the question: “Once in a while I wish she [therapist] would guess them [secrets]” (p. 343). Perhaps OSN profiles can strengthen the therapeutic alliance by substantiating guesses about such secrets. Farber et al.’s study was conducted with an older age group than the target demographic of discussion, but a strong PSYCHOSOCIAL MEDIA 86 therapeutic relationship is similarly important with youth and has shown to be an important factor in successful youth therapy outcome (Karver, Handels- man, Fields, & Bickman, 2005. Therefore integration of OSNs may be a tactic best employed after sever- al sessions to ensure that a therapeutic relationship has been firmly established and online profiles can be placed in context with previous in-person disclosures. Alternatively, for some adolescents and young adult clients, a psychosocial media adjunct may prove more fruitful during the beginning stages of therapy. Research shows that the therapeutic alliance gener- ally forms in the beginning phases of psychological treatment and helps to predict positive psychother- apy results (Henry & Strupp, 1994; Horvath, 1993; Martin, Garske, & Davis, 2000). Scrolling through a client’s profile may initially increase clients’ feelings of anticipatory shame. Yet for some individuals – es- pecially for those who are shy or socially anxious – it may reduce such shame compared to face-to-face dis- closures. Online resources, in their varied forms, can often help facilitate social relationships and overcome shyness (Maczewski, 2002; Valkenburg, Schouten, & Peter, 2005). OSNs are inherently engagement tools, and if a non-engaging or shy client actively uses on- line social tools prior to treatment, these tools can perhaps provide clues about how to engage the cli- ent by colorfully exhibiting his interests, attitudes, beliefs and interpersonal style. OSN access may ease disclosure during the beginning – critical – phases of therapy by engendering feelings of positive re- gard, which also play an important role in positive psychotherapy outcomes (Farber & Doolin, 2011). In a general way, OSN integration may engender a sense of congruence because the therapist is active- ly seeking to understand and appreciate the genera- tional interests and interpersonal world of the client. A recent study looked at the course of action by clinicians that increases depth of elaboration and therapeutic alliance (Lingiardi, Colli, Gentile, & Tan- zilli, 2011). The depth of elaboration is defined as the “dimensions of the quality of the psychothera- py sessions,” essentially whether they are powerful/ weak, valuable/worthless, deep/shallow, full/empty and special/ordinary (p. 391). One key finding in- dicated that relational patterns play a role in both depth and alliance. It is therefore important to help “explore, with the client, their interpersonal issues, identifying recurring themes and relational patterns in clients’ past relationships…” (p. 398). The study also found that therapists could increase the depth of elaboration and therapeutic alliance by focusing interventions on client emotions, especially those regarded by the client as unacceptable (i.e. anger, resentment, envy). It seems that both client rela- tional patterns and affect are evident on OSN pro- files, which may be useful for a clinician to question. If therapists or clients believe that social media access would potentially disrupt the alliance or gen- erate misleading information, then it should not be utilized. For those who do not share personal details on OSN or are not active users, this instrument of investigation may be especially ineffective. There is no manual on how to interpret social media ac- tivity in therapy sessions just yet. There is, howev- er, ample literature supporting the use of photogra- phy and autobiographical storytelling as adjuncts in therapy. OSNs seem to be a combination of both. Visual Expression in Psychotherapy Sharing and viewing photographs and videos is one of the biggest allures of Facebook. There are over 300 million photographs uploaded daily on Facebook alone, making it the most popular photo uploading service on the web (Facebook, S-1 Filing, 2012). Also becoming increasingly popular are photo and video sharing, organizing and editing applications and sites such as Pinterest, Instagram, YouTube and Vine, and these could also take on meaning in a therapy session, especially because images are subjectively taken and interpreted (Banks, 2001; Coover, 2004; Dicks, Soyin- ka, & Coffey 2006; Lister & Wells 2001; Pink, 2004). In 1980, Fryrear surveyed previous research on phototherapy and identified 11 document- ed uses of photography in psychotherapy: evok- ing emotional states, developing skills, facilitating verbal behavior, modeling, socialization, self-con- frontation, help in making diagnoses, fostering expression and creativity, documentation of ther- apeutic changes, prolonging of meaningful experi- ences, and helping to promote verbal communica- STONE 87 tion between the therapist and client (Fryrear, 1980). Recent literature has further suggested that im- ages can be interpreted as objects of communication rather than just memory (Van House, 2011), and can be used as an adjunct in treating an array of disor- ders including alcohol abuse (Dollinger, Rhodes, & Corcoran, 1993), schizophrenia (Phillips, 1986), and eating disorders (Wessels, 1985), as well as popula- tions including: family therapy (Kaslow & Fried- man, 1977; Ruben, 1978) and adolescents (Blinn, 1987; Vardell, McClellan, & Fryrear, 1982). The act of exploring photographs in particular has shown to help clients conjure past events and memories, un- earth emotions about interpersonal relationships, re- late images from the past to the present, and form a better understanding of identity. OSNs – with their emphasis on personal photos – may be of particu- lar use in therapy to address excessive concerns or idealizations of body image for those suffering from eating disorders or Body Dysmorphic Disorder. Psychologist and art therapist Judy Weiser in her paper, “ ‘See What I Mean?’ Photography as Nonver- bal Communication in Cross-Cultural Psychology” argues that photography is a form of nonverbal com- munication that can be interpreted as the “… con- scious and unconscious self, moments of importance chosen for whatever personal reasons to be frozen in time forever, and if deemed successful, kept and trea- sured as items of value” (p. 245). She later explains how photo-exploring techniques, in a phenomeno- logical and existential model can “guide discoveries where words cannot go” (p. 254). Based on her use of photography as a therapeutic tool, she argues that clients rarely understand the extent to which they re- veal themselves in their photographs. In addition, she points out that even a lack of photos is telling because people don’t keep photos of people or moments they do not cherish, and these voids of people and rela- tionships are areas that can initiate further question- ing. Weiser’s paper however was written prior to the advent of interactive online photo sharing, which im- plies that newer, more interactive forms of photogra- phy may bring about even more explicit projections. Through simple digital communications such as com- menting, “liking,” “tweeting” and even “retweeting” individuals create their perceived stimulus, because photos begin to “take on a life of their own, almost apart from our process of visual perception” (p. 263). In addition, the comments beneath shared pho- tos or videos on OSNs provide clues as to conveyed identity, and can therefore be a lens into a patient’s interpersonal feedback (p. 276) – perhaps more so than a photograph with no associated activity from a network of friends or followers. In order to better understand a client’s interrelating system as a whole, it may behoove a therapist to interpret OSN dis- closure from a narrative psychological perspective. OSNs as Narrative Another important component of Facebook, likely unbeknownst to its over one billion users, is that it is an emotionally-laden, narrative-generating tool. In many ways, psychotherapy is also the pro- cess of guiding people in formulating their life sto- ries. Psychologist and writer Nancy McWilliams (2004) spoke to the narrative capabilities of psycho- therapy, “...we regard the project of psychotherapy as a joint effort to develop a narrative that makes sense of a person’s subjective experience and per- sonal problems” (p. 139). On Facebook in particu- lar, a new generation is quite literally constructing their life timelines. While visiting the profile of a “friend” one can scroll through – chronologically – all of the pictures, comments, quotes, “likes,” going back to the very day that they signed up for the so- cial network (depending on the specific aspects of their profile that they choose to share). Facebook has become an interactive autobiography of sorts. This is powerful, and considering the amount of time teenagers and adults spend on Facebook, these online self-presentations may play a role in shaping self-identity (Valkenburg, Schouten, & Peter, 2005). So what does this collage of social activity – friends, family life, interests – actually mean, and how can it effectively be harnessed in a clinical set- ting? Psychotherapists might glean a more compre- hensive conceptualization of their client if they do so from a narrative framework. As psychologist and legal expert Jerome Bruner (1991) wrote in his pa- per Narrative Construction of Reality, “…we know altogether too little about how we go about con- PSYCHOSOCIAL MEDIA 88 structing, and representing the rich and messy do- main of human interaction” (p. 4). Narratives rep- resented on OSNs may provide a clue. Psychologist Theodore Sarbin (1986) believed that narrative was a root metaphor for psychology and that human functioning is inherently contextual (Sarbin, 1986). He argued that narrative is so embedded in human functioning that it is easily forgotten as a metaphor for psychology. Similarly, OSNs are becoming em- bedded into the culture of a new generation, be- coming root metaphors for psychology. Even the founder of Facebook and former undergraduate psychology major at Harvard University, Mark Zuck- erberg described his company as being “as much psychology and sociology as technology” during a 2011 speech (Larson, C. Desert News. Mar 25, 2011). Psychotherapists can play a critical role in help- ing shape their clients’ personal narratives through joint investigation of their OSN profiles. One pro- posed method of doing so is to examine online photographic narratives (photo albums) through the lens of gender and sexual identity (Kaufmann, 2007). Kaufmann describes distinct layers of inter- pretation in analyzing online photographic narratives, one of which is the message itself. When an individ- ual views an image on a computer screen, they are “actively and subjectively” building meaning, more so than in movies because there is more interactiv- ity on the web and the viewer can be in “one, two, or a hundred different places at once… focus turns inward and internal fantasy becomes ‘real’, and the outer world diminishes” (p. 10). In some ways, as tangible as thoughts and images are on OSNs, they are also representations of fantasy. Another ques- tion to consider is why certain photos are chosen as profile photos and others as large cover photos (the long images spanning the top of the newly-designed personal Facebook profiles.) Facebook and Twitter in particular are constructed in such a way that allows users to emphasize certain idealized images over oth- ers, to emphasize and promote biographical details, attitudes, and interests. On Facebook, one photo is the profile image, a representation of a person. The larger background photos are additional space to pro- vide context and further expressions of individuality. Narrative psychology, a field of study and practice, provides principles that may inform the integration of OSN and psychotherapy. In his paper “Metaphor and Medicine,” psychiatrist Jack Coulehan describes patients as understanding their suffering in a “nar- rative way whether their physicians realize it or not” (Coulehan, 2003, p. 87). Coulehan further argues that narrative should be an essential aspect of contempo- rary medicine and be bound to the tools of medicine. He says that words, images, metaphors and symbols are integral in day-to-day practice and that medicine is not above or beyond culture. Perhaps the tools of narrative may be even more adeptly applied to clinical psychology, a healing practice rooted in emotion, em- pathy and disclosure. OSN profiles offer insight into the experience-near language, metaphors and sym- bols of a client’s interpersonal world. When utilizing OSNs, it may even be useful to question and test for accurate understanding and perception of content, a process of reflection pioneered by Carl Rogers (Rog- ers, 1986). Hypothetical examples of such questions might include: Am I correct in saying that you are telling others with this photo album that you are fun loving and adven- turous? Or, Based on your sarcastic or negative status updates, it seems like this week was pretty tough for you, am I right? By better understanding the story an individual pres- ents on their profile, a therapist may glean a better understanding of their interpersonal world and how they order events outside the confines of the clinical office. Richert (2006) states that the goal of psycho- logical treatment is to help a person actively construct healthy narratives where the person – as opposed to outside forces – is the author. Yet the question re- mains: in what larger theoretical framework might a psychosocial media approach effectively work? Modes of Psychosocial Media In their review of technological adjuncts in psy- chotherapy, Clough and Casey (2011) note that there has been “very little research examining the suitabil- ity of technological adjuncts to different types of therapy” and argue that “future research should ad- dress whether particular therapies are more amena- ble to making use of adjunctive technologies than others” (p. 290). Perhaps Richert’s (2006) mode of integrating narrative psychology into psycho- STONE 89 therapy may provide clues as to how OSNs can be integrated into psychotherapy using a larger psy- chodynamic or cognitive-behavioral framework. Based on the tone, language and mood present- ed, the nature of the client’s story may reveal itself and can be used as a basis for selecting a therapeutic approach (Richert, 2006). In his paper on the inte- gration of narrative psychology into psychotherapy, Richert argues that a useful way to categorize client stories is by distinguishing between their “agency” and “communion” (Bakan, 1966),the former being the sense of individuality and pursuit of personal goals, and the latter signifying the pursuit of “shared goals of the common good” (Richert, 2006, p. 91). Richert labels an individual’s sense of agency or com- munion as “relatedness” – how a person positions himself toward others – and believes that it has an impact on the therapy relationship. Essentially he dif- ferentiated how individuals rely on external informa- tion or rely more on their own inner experiences and intuition (Richert, 2006). Both seem to be present in OSNs. Perhaps some client’s relatedness towards others lean more towards agency over communion, and vice versa. Although OSNs are generally built to share information publicly, they are not always mech- anisms for the act of sharing in the “common good.” Despite the public-nature of Facebook, much of what is shared contains Richert’s (2006) notion of agency i.e. preferred news articles, group affilia- tion, self-image, and self-identity and other personal attitudes. Richert fits various theories into “agentic” and “communal” classifications. In particular, he ar- gues that the analytic, behavioral, person-centered and Gestalt theory fit within the “agentic” bucket be- cause they focus almost exclusively on the individual, whereas cognitive, narrative, existential, solution-fo- cused and interpersonal therapies fit best in a more communal classification because they focus more on connectedness with others (Richert, 2006, p. 99). There seems to be a number of ways to interpret an individual’s OSNs. Each clinician could incorpo- rate or apply his or her own therapeutic framework in helping to utilize OSN client profiles. For exam- ple, a psychodynamic framework may connect a cli- ent’s maladaptive online behaviors with past familial relationship patterns, allowing for a more visual un- derstanding of relational functioning. Alternative- ly, a cognitive behavioral approach may challenge the cognitive distortions a client expresses about the comments or feedback he or she is receiving on their profile and implement behavioral modifi- cations, i.e. changes in the frequency of OSN use. In his 2001 paper, Davis introduces a CBT model for treating Internet addiction and ex- plores the way exposure therapy and behavior- al changes can potentially bring about positive psychological outcomes for Internet addiction: Exposure therapy might include keeping the cli- ent away from the Internet for a period of time, having the client observe that nothing negative actually happens if they are offline, and finally, having the client observe his or her own cog- nitive reactions to the Internet by multiple ex- posures to various Internet functions (p. 194). After observing a client’s OSN behavior alongside them (exposure to various Internet functions), a client may be more receptive to making behavioral changes. In general, when it comes to technological adjuncts, therapists with cognitive behavioral back- grounds more frequently endorse new technologies in psychotherapy (Mora, Nevid, & Chaplin, 2008). Other Examples of Technology Used in Psychotherapy It is important to note that psychotherapy has not completely spurned new media. Clough & Casey’s review (2011) identified six key areas in which tech- nology has been used in psychotherapeutic practice: mobile phones, Personal Digital Assistants (PDAs), biofeedback, Virtual Reality (VR), computer games and electronic questionnaires. A number of recent studies have found that Internet-based interventions – particularly for CBT (cognitive behavioral thera- py) – are promising in reducing symptoms of mild to moderate depression (e.g. Foroushani, Schneider, & Neda, 2011), anxiety (e.g. Craske et al., 2009) and panic disorder (e.g. Klein, Richards, & Austin, 2006). Mental health professionals today often pro- mote the use of video conferencing tools such as Skype or email to correspond with their clients, al- PSYCHOSOCIAL MEDIA 90 though most practitioners agree that it is best used as a supplement to face-to-face meetings. Still, OSNs constitute a different media platform. Most estab- lished psychologists rarely use OSNs themselves, and lack knowledge to provide a supervisory guid- ance (Taylor, McMinn, Bufford, & Chang, 2010). As mentioned, Internet-cognitive behavioral therapy (iCBT) has proved to be a useful vehicle for CBT, and in many instances is as equally effective as face- to-face CBT. While these advancements are positive utilizations of emerging media, they are mere facilita- tors, as opposed to remnants of human interaction, attitude, emotion and personality. While burgeoning mechanisms such as Skype, email, chat, virtual real- ity exposure therapy, iCBT and mobile applications can grease the wheels of disclosure and enhance the therapeutic process, they do not generally contain the elaborate content of unconscious emotions and conscious expressive representations found in OSNs. Conclusion The 2009 Presidential Task Force on the Future of Psychology Practice (American Psychological As- sociation, [APA], 2009) recommends that psycholo- gists be trained “to use and integrate technologies to provide quality services” (p. 5). Social scientists are being encouraged to utilize and tap into the psychol- ogy behind the digital landscape, but the question remains: what implications do these self-disclosures and self-presentations on OSN have for clinicians? Social tools such as Facebook, Twitter, Tumblr, Instagram, as well as dating sites and apps have col- lectively attracted billions of users who have creat- ed billions of virtual interpersonal connections and shared countless articles of personal information. These points of contact and presentations are filled with clues as to how individuals express themselves and manage relationships in a digital ecosystem. In addition, it has raised questions about how people use OSNs and how personalities are reflected in its usage. While OSN personality data remains inconclusive, re- cent findings indicate that personality processes are salient on OSN and, more often than not, parallel the processes in direct, face-to-face environments (Gos- ling, Augustine, Vazire, Holtzman, & Gaddis, 2011). Going back in timeline fashion on Facebook, there are traces of personality, previous love inter- ests, political affiliations, attitudes about current events, words of wisdom, biographical information, the crowd-sourcing of advice from ones network, displays of frustration, aggression or perhaps even cyberbullying or suicidal behaviors. All of these con- tain hints of individuation, agency, and interpersonal styles or communion. While these traits and behav- iors exist on a continuum of therapeutic importance, all are uniquely significant. In essence, while OSNs are filled with trivialities and banalities they addi- tionally contain abundant exclamatory material that color the emotional well being of clients and may provide greater therapeutic context and content. As social media technology has advanced and di- versified over the past several years, the number of OSN users has expanded beyond college campuses. This is especially true of Facebook. Yet questions also remain as to how Facebook use differs from everyday face-to-face communication, or from oth- er media sources such as television, radio or video games (which are also expanding their services to the web and becoming more socially-oriented). Some re- searchers argue that Internet-based communication is a combination of many past media advancements (Bargh & McKenna, 2004), but given the addic- tive- and interactive-nature of Facebook – over 250 million photos uploaded daily and over 100 billion friendships (Facebook, S-1 filing, 2012) – it is clear that OSNs are a much more public and measurable medium seemingly ripe for utilization in therapy. Understandably, some clients and therapists will view this proposed psychosocial media intervention as a breach of privacy or a shallow endeavor. It may indeed be true that only those mental health profes- sionals and clients already conversant in OSNs would profit from this joint exploration. Another appre- hension is that a client’s social activity would include comments and/or photos from unwitting friends or followers. Presumably, these friends and follow- ers would consider their OSN interactions private or, at least, limited to a controlled following. Per- haps even more concerning is the possibility that a clinician personally recognizes individual(s) who are visible on a client’s OSN. This could create a con- STONE 91 flict of interest and raises further questions regarding how client privacy issues differ in the digital space. Nonetheless, in the same way a fireman must find the location of a blaze, a therapist must tirelessly work to locate the core of emotions. If the emotion- al fire rests somewhere in a person’s digital domain, then there a therapist should cautiously turn. How- ever even if a direct OSN approach is not feasible, a more indirect, hands off approach may be more com- fortable. It seems reasonable to inquire about OSN activity in therapy, especially for adolescents, young adults, or those individuals who spend an inordinate amount of their time using this technology. Ques- tions might include: How much time do you spend online? Are you on Facebook or Twitter? How many friends/followers do you currently have? Are you ever bullied online? These questions can open a new path into the unconscious, as well as bring to light present cognitions, emotions and maladaptive behaviors. In doing so, they may strengthen the therapeutic alliance. An individual’s personal OSN profile may be safer being explored alongside a trained mental health professional who maintains perspective and a pulse on their emotion- al sensitivity and overall functioning versus friends, family or acquaintances who are not clinically trained. The “likes,” posts, pokes, pictures, comments, group membership, friendships, re-connections of the so-called Facebook Generation will become part and parcel of their social and emotional schemas as they grow into adults. Likewise even older adults will assimilate new social technology into their ex- isting interpersonal schemas. Understanding and exploring the psychology behind these often-seem- ingly trivial social tools can be beneficial to the 21st century therapist. 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