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New Ethical Dilemmas in the Digital
Age
Use of technology
by counselors
• is increasing
• presents unique
ethical dilemmas
(NBCC Policy, 2013)
Presentation Outline
1. History of Technology Use in Counseling
2. Digital Types
3. Social Media
4. Ethics - Counselor Sel...
Ethics codes cannot do our questioning, thinking, feeling,
and responding for us. Such codes can never be a
substitute for...
HISTORY OF TECHNOLOGY USE IN COUNSELING
Audio Taping Clients Began?
1942 by
Carl Rogers
(Rogers,1942)
3 waves in the
advancement of technology
(McMinn, Buchanan, Ellens, & Ryan, 1999)
1. Fax machines, Word processors, answering
machines, and voice mail machines
In 1999, experts predicted advances in
techn...
Did we have ethical codes
regarding using fax machines
or voice mail ten to fifteen
years ago?
AND NOW…..
Technology has invaded our lives …
(Dixon, 2013)
… and its Creeping into clinical practice
(Mishna et al., 2012)
Technology ‘Creep’
• Lack of literature and research to
provide guidance
• Technology may be used as part of the
‘Therapeu...
Practitioners are vulnerable to being
blindsided by NEW ethical dilemmas
(Crowley & Gottlieb, 2012)
“Why did I not see this coming?”
(Crowley & Gottlieb, 2012)
Some professionals are….
…ethically astute but
struggle to keep up
with the technology. …comfortable with
technology but l...
‘Adapting to the
new culture wisely will necessarily
involve both understanding the
ethical principles themselves as
well ...
DIGITAL TYPES
Digital Immigrants
(Zur, 2012; Prensky, 2001)
Digital Immigrants
… people born before or about 1964 and
who grew up in a pre-computer world
(Zur & Zur, 2011)
Digital Immigrant
Like all immigrants… as Digital Immigrants
learn to adapt to their environment, they
retain, to some degree, their ‘accent...
I am a digital
immigrant…
Digital Accent…
‘native speakers’ of the digital language
of computers, cell phones, video games,
and the Internet (Zur, 2012; Prensky, 20...
‘Digital DNA’
flowing through
their bodies
DIGITAL
NATIVES
(Zur & Zur, 2011)
Digital Immigrants Digital Natives
• Prefer to talk in-person or
on the phone
• Prefer to talk via chat, text, or
messagin...
Other Digital Types
Ways to sort people other than age
• Attitudes
• Comprehension
• Relationships
• Practices
• Comfort w...
Avoiders
• ‘Luddites’ - true avoiders of modern
technologies
• Use landlines; avoid email and the Internet
• Newspapers ar...
Minimalists
• Use technology reluctantly
• Could be digital immigrant-reluctant
adopters or digital native minimalists
• H...
Tourists
• Visitors in the digital world
• Pay attention to the 'local' or 'native' digital
culture, learn its language, o...
Enthusiastic or Eager Adopters
• Have fun with technology
• Enjoy the latest smart phone & tablet
• Ready & excited to try...
Innovators
• Are not only enthusiastic, they work with
technology to improve it
• This group includes game developers,
pro...
Digital Over-Users/Problematic Users
• Heavily dependent on technology to occupy their
time….many of them are gamers
• Exc...
75% of SUD treatment workforce
is over the age of 40
(Knudsen, 2003)
Average age of Clinical Directors is 52…
60%are over the age of 50
(Ryan, Murphy, & Krom, 2012)
(Ryan, Murphy, & Krom, 2012)
Almost one-third of clinical directors
report that they are only somewhat
proficient in web-b...
Almost 70% of individuals who received SUD
services were under the age of 40
( TEDs Data; SAMHSA, 2011)
DIGITAL DIVIDE
SOCIAL MEDIA
Social media is a broad term
that refers to online forms of
communicating that any individual
can employ as opposed to
‘in...
Web
Cell phones
Social Network Sites
Use of the Internet
87%of Americans
use the Internet
(Fox & Rainie-Pew Report,2014)
(http://pewinternet.org/Infographics/2013/Health-and-Internet-2012.aspx)
(http://pewinternet.org/Infographics/2013/Health-and-Internet-2012.aspx)
(Pew Research Center, 2012)
FB remains
dominant
platform
There was
little room
left for FB
growth
among teen
social media
users
Use Cell Phones & Text Messages
90% of American adults
have cell phones
58% have smart phones (Pew Report,2012)
No matter a person’s salary….
more people own cell phones
than use the internet
(Fox, 2013)
37% have gathered health
information on their phones
Almost 20% have a health app
(Fox, Dugan, & Purcell, 2013; Pew Report...
Americans now spend an average of
34 hours per month using mobile
apps and mobile web browsers
but only 27 hours a month
g...
29% of Americans own a tablet
The average American owns
four technology devices
(Digital Consumer Report, 2013)
80%send and receive
text messages
(Pew Report, 2012)
Perpetual texters …
• adolescents (aged 13–17) sending or receiving
3,339 texts a month(six text per waking hour)
• young ...
(McClure, Acquanta, Harding, & Stitzer, In Press)
• Survey of 8 urban drug treatment clinics
in Baltimore (266 patients)
•...
Social Network Site
… a website that provides a venue for
people to share their activities with
family, friends, and colle...
SNSs are a specific type of social
media that allow individuals to:
• construct a public or semipublic profile
within a bo...
Examples of Social Network Sites
• Facebook
• LinkedIn
• Instagram
• Pinterest
• Virtual Worlds
• Blogs
• Micro Blogs-Twit...
Social Networks
the No. 1 U.S. social networking site
1.11billion active users
665 million users log on to Facebook in any...
http://expandedramblings.com/index.php/resource-how-many-people-use-the-top-social-media/
277 million users – February 2014
Business Review Sites
120 million users – 53 million reviews
Smith, 2014
YELP Review Site
Virtual Worlds
Mental health professionals are now
employing virtual worlds in treating
• Asperger Syndrome
(Mangan, 2008)
• Combat-relat...
BLOGS
tumblr
http://expandedramblings.com/index.php/resource-how-many-people-use-the-top-social-media/
216 million users – 109 m...
Micro-blogging
243 million active users
http://expandedramblings.com/index.php/resource-how-many-people-use-the-top-social...
Twitter
Feed
Counselor Listservs
Counselor Listservs
Since clients are likely to use SNSs it may
be helpful for counselors/therapists to
understand the phenomena of SNSs, even...
ETHICS & TECHNOLOGY
Ethical Issues
• Ethical Codes and Technology
• Ethics and Self Disclosure
– Self Disclosure Definition/Guidelines
• Self ...
Ethical Codes and Licensing Boards
have not caught up
with the TECHNOLOGY
In some cases … provide little guidance
Other boards may use existing laws and
investigate complaints on the grounds of:
• Unprofessional conduct
• Unethical cond...
Counselor
Self Disclosure
Self-disclosure in psychotherapy is
defined as the revelation of
personal rather than professional
information by a psycho...
All psychologists
affirm the
importance of
being thoughtful
and intentional
about how they
handle issues of self
disclosur...
"All disclosures reflect decisions about
the boundaries between the private self
and the outer world.” (Farber, 2006)
Psychotherapist Self-Disclosure
• Unintentional
• Deliberate
• Accidental
• Verbal
• Nonverbal
• Avoidable
• Unavoidable
(...
Counselor Self-Disclosure
• BENIGN
• APPROPRIATE
• INAPPROPRIATE
(Zur et al., 2009)
Technology has
redefined the process of
Counselor Self-Disclosure
“Nothing that enters cyberspace is
ever completely secure”
(Collins, 2007)
Many social network users are
communicating in their virtual underwear
with few inhibitions (p. 45)
(Van Allen & Roberts, ...
Research found that 60% of medical
schools in the sample had posted
unprofessional online content, including:
• disclosure...
Clinicians must be
aware that all of
their online
postings, blogs, or
chats may be viewed
by their clients and
will stay o...
Interesting professional and ethical
challenges as the distinctions between
private and public information blurs.
(Behnke,...
Intertwining of the Internet
and clinical practice
(Clinton et al., 2010)
Rural areas and social network sites
are characterized by:
• pervasive incidental contact
• inevitable self-disclosure
• u...
4types of rural dilemmas that
involve multiple-role relationships
(Schank & Skovholt, 1997)
Overlapping social relationships
(Schank & Skovholt, 1997)
Overlapping Professional/Business
Relationships
(Schank & Skovholt, 1997)
overlapping
relationships
involving the
psychologists’
family
(Schank & Skovholt, 1997)
overlapping relationships involving the
psychologists’ clients with other clients
(Schank & Skovholt, 1997)
For example, just as transparency in rural
communities may involve increased
knowledge of a psychologist’s
whereabouts
som...
Even when a psychologist creates
concrete guidelines for himself or
herself around the area of self-
disclosure, the Inter...
Need to examine psychologists’
personal use of SNS outside of the
therapy hour & its impact on
psychologists’ reputation &...
Should counselors/therapists
participate in social network
sites as a private citizen?
(Lehavot, 2009)
Certainly, we need to be thoughtful about what
we post online and careful about whom we grant
access to ou...
Questions to Ask Yourself Before Posting
• What are the costs and benefits of posting the
information?
• Is there a high p...
Counselors Should Not POST
• post client information
• disparaging comments about colleagues or
client groups
• unprofessi...
Five Ethical Principles
• Nonmalefiscence - do no harm
• Autonomy-clients get to make their
own choices
• Beneficence-do g...
Ethical Reasoning
1. recognize that there is an event to
which to react
2. define the event as having an ethical
dimension...
Ethics Reasoning5. figure out what abstract ethical
rule(s) might apply to the problem
6. decide how these abstract ethica...
Legal Issues
Practitioners should contact both
their professional and personal
liability insurance representatives to
dete...
EMAILING & TEXTING PATIENTS -
PRIVACY & SECURITY
Privacy, Security, & Confidentiality Issues
SO WHAT’S THE
“electronic exchanges”
Emailing Clients
Security of Email
• Emails are stored at multiple locations: the
sender's computer; your Internet Service
Provider's (ISP)...
‘Email is not like
mailing a sealed letter
or package. It’s more
like sending a postcard
– people are not
supposed to read...
HIPAA New Rule Regarding Email
• Privacy Rule allows providers to communicate
electronically with patients
– Reasonable sa...
Re-Targeting
Do you or your staff
TEXT clients?
More than one-third of cell phone users
(http://www.saurageresearch.com/key-findings-novemberdecember-2009/)
• have sent a...
TEXTING
Miscommunications
Text Messages
can be saved,
sent to an email
account, and
posted online all
without the other
person’s
permission
Confidentiality
Text Message
Transmission
Process
“Traditional Short Message Service (SMS)
text messaging is non-secure and non-
compliant with safety and privacy
regulatio...
“No it is not acceptable for physicians or
licensed independent practitioners to text
orders for patients to the hospital ...
To ensure the patient’s privacy clinicians
should consider the use of encrypted email
systems or portal messaging systems ...
Safe
Practices
maintain physical control of
your mobile device/computer
(http://www.HealthIT.gov/mobiledevices)
unsecured
networks
(http://www.HealthIT.gov/mobiledevices)
unintentional disclosure
(http://www.HealthIT.gov/mobiledevices)
check out what is
downloaded on your
mobile device/computer
and keep the security
software updated
(http://www.HealthIT.go...
activate wiping and/or remote disabling
(http://www.HealthIT.gov/mobiledevices)
use a secure portal to
send or receive PHI over
public Wi-Fi networks(http://www.HealthIT.gov/mobiledevices)
Implement policies & procedures to
restrict access to,
protect the integrity of, &
guard against unauthorized access to
el...
Do you or your agency have
a social media policy?
SOCIAL MEDIA POLICY ISSUES
For Clients and/or Staff?
Whether the counselor accepts friend
requests from social networking sites
(Kaplan, Wade, Conteh, & Martz, 2011)© Keely Ko...
If a client friends you and you accept
them, they have access to your pictures
Halloween Party
2012
Whether clients can be a Facebook
friend of the counselor
(Kaplan, Wade, Conteh, & Martz, 2011)© Keely Kolmes, Psy.D. – So...
LIKING
Whether clients may be a follower of
the counselor on Twitter
(Kaplan, Wade, Conteh, & Martz, 2011)© Keely Kolmes, Psy.D. ...
Our opinion is that engaging in
friending and following
those whom we serve, supervise,
teach, or collect research data
fr...
(Zur, 2010)
Whether clients can text, email, or
take phone calls during sessions?
Sometimes use of technology in
session provides counselor/therapist
with greater insight (Zur, 2010)
(Kaplan, Wade, Conteh, & Martz, 2011)© Keely Kolmes, Psy.D. – Social Media Policy – 4/26/10
Whether you utilize listservs ...
Online
Consultations
increase the possibility of inadequate
and simplistic solutions being offered
Kaslow, Patterson, & Gottlieb, 2011
ONLINE C...
risk of violating client
confidentiality unless identifying
information is well camouflaged
Kaslow, Patterson, & Gottlieb,...
Unless the person seeking consultation
knows the counselor who is responding,
he or she has no assurance about the
efficac...
Whether messaging through social
network sites such as Linkedln or
Facebook can be used to interact
with the counselor
(Ka...
FACEBOOK CHAT
“Clients should know that electronic
communications are generally not secure
methods of communication and there is a risk
...
The conditions under which
Google, Facebook, or other search
engines may be used to find out
information about a client
(K...
The accessibility, anonymity,
and universality of the Internet have made it
easier and more tempting to “Google” clients
Prevalence of Googling
• 22% of 193 clinical psychology graduate
students had Googled their psychotherapy
clients (Martin,...
• 98% of doctoral psychology students
had searched for at least one client’s
information over the past year… even
though m...
Is it infringing on a patient’s privacy?
Patient Targeted Googling …
Would it be okay for a counselor to
drive by a clients’ house?
33 Things to Consider Before
Conducting Patient Targeted Googling
• consider the intention of the search
• evaluate the po...
More in depth questions
1. Why do I want to conduct this search?
2. Would my search advance or
compromise the treatment?
3...
4. Should I share the results of the search
with the patient?
5. Should I document the findings of the
search in the medic...
On the other hand
With the click of a mouse, clients can find a
wealth of information on their counselors
about their psychologists online
(...
Some personal information about
the clinician may be available to the
client without the psychotherapist’s
knowledge or ap...
In some cases psychologists in training
had either been matched with
current/former clients through
anonymous dating websi...
Clients Googling Counselors
70% of clients reported finding personal
information about their psychotherapist
on the Intern...
How do you respond if a client
tells you that he has “Googled”
you or visited your website?
Whether the counselor accepts
testimonials on his or her
various websites
(Kaplan, Wade, Conteh, & Martz, 2011)© Keely Kol...
The American Psychological Association’s
Ethics Code states under Principle 5.05
that it is unethical for psychologists to...
How the counselor may or may
not respond to comments or
ratings posted on internet sites
(Kaplan, Wade, Conteh, & Martz, 2...
How the counselor notifies clients
regarding GPS Notification Services
(Kaplan, Wade, Conteh, & Martz, 2011)© Keely Kolmes...
Confidentiality Issues…
(Kaplan, Wade, Conteh, & Martz, 2011)© Keely Kolmes, Psy.D. – Social Media Policy – 4/26/10
If the organization has a social
media policy?
Employees will share their
gripes and struggles on Twitter,
Facebook, YouTube, Instagram, and
any other site with friends ...
The NLRA is not just about unions and
collective bargaining….
This right extends to communications
with co-employees as we...
National Labor Relations Act
• Employers should still exercise considerable
caution when responding to complaints about
an...
The key that NLRB or judges try to determine is if
an employee is griping (complaining) for their
own self interest or on ...
When employees are reprimanded or
terminated for statements
they make online
the unwary employer may find that it has
inad...
2 Facebook Examples
(Morrison & Foerster, 2014)
Be careful with staff social media policy
Why don’t I draft a policy about this?
(Kasarjian, 2013)
Social Media Policy Sample
• Use Sample Policy Based upon
Walmart’s Policy
• Use examples
• Don’t use a summary statement ...
2Additional Issues
DON’T EVER
‘SHOULDER SURF’
or
MAKE AN
EMPLOYEE SHARE
THEIR PASSWORD
or
ASK THEM to
‘FRIEND YOU’
(Klemchuk & Desai, 2014)
10states … Arkansas, Colorado,
Illinois, Nevada, New Jersey, New Mexico,
Oregon, Utah, Vermont and Washington …
enacted le...
In a recent survey (2012) by
CareerBuilder…
approximately 37%of companies
indicated they use social networking
sites to re...
Companies need to be careful when
using social media in recruiting
employees and researching applicants
‘What is learned c...
CLINICAL SUPERVISION & TECHNOLOGY
Clinical Supervisors &
Technology: A Balancing Act
Counselor supervision is …
“the means by which skills are refined,
theory and practice are integrated, and
trainees explor...
Counselors may avoid seeking guidance on social
network/internet/technology issues because of a
perceived lack of supervis...
Importance of Supervisors
Conducting Self Assessments
Clinical Supervisors…
Have you asked your
supervisees if they email
or text clients?
Technology could create a threat to
usual patterns of supervision
Accessible
easy to approach & speak freely
Clinical Supervisors may provide face-to-face
supervision, online supervision, or a hybrid of
online and face-to-face appr...
Computer-based Clinical Supervision
(a) lower costs to supervisees
(b) increased flexibility in scheduling
(c) greater cos...
Online Clinical Supervision
• Online supervision should occur
through encrypted channels
• More investigation is needed in...
HIPAA Compliant
Training Substance Abuse Clinicians in
Motivational Interviewing (MI) using
live supervision via teleconferencing
Teleconf...
Supervisors should consider all the same
issues relevant to counselors and their
clients when considering sharing personal...
Questions
‘Ethical behavior does not arise solely
from habit or obedience to patterns or
rules but includes intelligently guiding
ou...
New Ethical Dilemmas in the Digital age
New Ethical Dilemmas in the Digital age
New Ethical Dilemmas in the Digital age
New Ethical Dilemmas in the Digital age
New Ethical Dilemmas in the Digital age
New Ethical Dilemmas in the Digital age
New Ethical Dilemmas in the Digital age
New Ethical Dilemmas in the Digital age
New Ethical Dilemmas in the Digital age
New Ethical Dilemmas in the Digital age
New Ethical Dilemmas in the Digital age
New Ethical Dilemmas in the Digital age
New Ethical Dilemmas in the Digital age
New Ethical Dilemmas in the Digital age
New Ethical Dilemmas in the Digital age
New Ethical Dilemmas in the Digital age
New Ethical Dilemmas in the Digital age
New Ethical Dilemmas in the Digital age
New Ethical Dilemmas in the Digital age
New Ethical Dilemmas in the Digital age
New Ethical Dilemmas in the Digital age
New Ethical Dilemmas in the Digital age
New Ethical Dilemmas in the Digital age
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New Ethical Dilemmas in the Digital age

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New Ethical Dilemmas in the Digital age

  1. 1. New Ethical Dilemmas in the Digital Age
  2. 2. Use of technology by counselors • is increasing • presents unique ethical dilemmas (NBCC Policy, 2013)
  3. 3. Presentation Outline 1. History of Technology Use in Counseling 2. Digital Types 3. Social Media 4. Ethics - Counselor Self Disclosure 5. Emailing & Texting Clients – Privacy & Security 6. Social Media Policies 7. Clinical Supervision & Technology
  4. 4. Ethics codes cannot do our questioning, thinking, feeling, and responding for us. Such codes can never be a substitute for the active process by which the individual therapist or counselor struggles with the sometimes bewildering, always unique constellation of questions, responsibilities, contexts, and competing demands of helping another person. Ethics must be practical. Clinicians confront an almost unimaginable diversity of situations, each with its own shifting questions, demands, and responsibilities. Every clinician is unique in important ways. Every client is unique in important ways. Ethics that are out of touch with the practical realities of clinical work, with the diversity and constantly changing nature of the therapeutic venture, are useless. (Pope & Vasquez, 1998, xiii–xiv)
  5. 5. HISTORY OF TECHNOLOGY USE IN COUNSELING
  6. 6. Audio Taping Clients Began?
  7. 7. 1942 by Carl Rogers (Rogers,1942)
  8. 8. 3 waves in the advancement of technology (McMinn, Buchanan, Ellens, & Ryan, 1999)
  9. 9. 1. Fax machines, Word processors, answering machines, and voice mail machines In 1999, experts predicted advances in technology for therapists/counselors (McMinn, Buchanan, Ellens, & Ryan, 1999) 2. Enhancement of test administration, scoring, and interpretation 3. Use of telephone, e-mail, and chat rooms
  10. 10. Did we have ethical codes regarding using fax machines or voice mail ten to fifteen years ago? AND NOW…..
  11. 11. Technology has invaded our lives … (Dixon, 2013)
  12. 12. … and its Creeping into clinical practice (Mishna et al., 2012)
  13. 13. Technology ‘Creep’ • Lack of literature and research to provide guidance • Technology may be used as part of the ‘Therapeutic Exchange’ and then WHAT? – Documentation of the exchange – Guidelines for the exchange (Gabbard et al., 2011; Mishna et al., 2012)
  14. 14. Practitioners are vulnerable to being blindsided by NEW ethical dilemmas (Crowley & Gottlieb, 2012)
  15. 15. “Why did I not see this coming?” (Crowley & Gottlieb, 2012)
  16. 16. Some professionals are…. …ethically astute but struggle to keep up with the technology. …comfortable with technology but less familiar with ethical codes. (Lannin & Scott, 2013)
  17. 17. ‘Adapting to the new culture wisely will necessarily involve both understanding the ethical principles themselves as well as developing competence in the technology of the burgeoning digital culture.’ (Lannin & Scott, 2013)
  18. 18. DIGITAL TYPES
  19. 19. Digital Immigrants (Zur, 2012; Prensky, 2001)
  20. 20. Digital Immigrants … people born before or about 1964 and who grew up in a pre-computer world (Zur & Zur, 2011)
  21. 21. Digital Immigrant
  22. 22. Like all immigrants… as Digital Immigrants learn to adapt to their environment, they retain, to some degree, their ‘accent’ … What is your digital accent? (Prensky, 2001)
  23. 23. I am a digital immigrant… Digital Accent…
  24. 24. ‘native speakers’ of the digital language of computers, cell phones, video games, and the Internet (Zur, 2012; Prensky, 2001)
  25. 25. ‘Digital DNA’ flowing through their bodies DIGITAL NATIVES (Zur & Zur, 2011)
  26. 26. Digital Immigrants Digital Natives • Prefer to talk in-person or on the phone • Prefer to talk via chat, text, or messaging thru social media • Don’t text or only sparingly • Text more than call • Prefer synchronous communication • Prefer asynchronous communication • Prefer receiving information slowly: linearly, logically, & sequentially • Prefer receiving information quickly & simultaneously from multiple multimedia & other sources • Prefer reading text (i.e., books) on processing pictures, sounds & video • Prefer processing /interacting with pictures, graphics, sounds & video before text Comparison of Digital Types (Zur & Zur, 2011; Rosen, 2010; Prennsky, 2001)
  27. 27. Other Digital Types Ways to sort people other than age • Attitudes • Comprehension • Relationships • Practices • Comfort with technology (Feeney, 2010; Toledo, 2007)
  28. 28. Avoiders • ‘Luddites’ - true avoiders of modern technologies • Use landlines; avoid email and the Internet • Newspapers arrive via carrier, not Internet server • Can be old digital immigrants who cannot relate to modern technology • Can be digital natives who some may call ‘Neo-Luddites’ - philosophically oppose the use of the Internet and other modern online technologies (Feeney, 2010; Toledo, 2007)
  29. 29. Minimalists • Use technology reluctantly • Could be digital immigrant-reluctant adopters or digital native minimalists • Have an email account and probably a Facebook profile but do not check them regularly • Have a cellphone, but do not need or desire to be online via the phone • No smartphones are necessary/wanted • Reads the newspaper in paper form (Feeney, 2010; Toledo, 2007)
  30. 30. Tourists • Visitors in the digital world • Pay attention to the 'local' or 'native' digital culture, learn its language, observe its rituals, and comprehend its complexities • Keep internal distance from technology even though they tend to use it appropriately and effectively, as needed, but not extensively • Stays internally non-digital in regard to preferences and values (Feeney, 2010; Toledo, 2007)
  31. 31. Enthusiastic or Eager Adopters • Have fun with technology • Enjoy the latest smart phone & tablet • Ready & excited to try out the product of a friend & enjoy the process • Participate in online discussions via Facebook, news sites, blogs, or online education • Write online content themselves • Check email & online throughout the day • Get their news online, not via print (Feeney, 2010; Toledo, 2007)
  32. 32. Innovators • Are not only enthusiastic, they work with technology to improve it • This group includes game developers, programmers, engineers, technology writers, professors, and hackers (Feeney, 2010; Toledo, 2007)
  33. 33. Digital Over-Users/Problematic Users • Heavily dependent on technology to occupy their time….many of them are gamers • Excessive internet use for gaming, porn, social networking, gambling, etc • Extremely protective of their "right" to be online • Can become upset, irate, and even violent if technology is not available • Lives are significantly, negatively affected by their excessive use of digital technologies (Feeney, 2010; Toledo, 2007)
  34. 34. 75% of SUD treatment workforce is over the age of 40 (Knudsen, 2003)
  35. 35. Average age of Clinical Directors is 52… 60%are over the age of 50 (Ryan, Murphy, & Krom, 2012)
  36. 36. (Ryan, Murphy, & Krom, 2012) Almost one-third of clinical directors report that they are only somewhat proficient in web-based technologies
  37. 37. Almost 70% of individuals who received SUD services were under the age of 40 ( TEDs Data; SAMHSA, 2011)
  38. 38. DIGITAL DIVIDE
  39. 39. SOCIAL MEDIA
  40. 40. Social media is a broad term that refers to online forms of communicating that any individual can employ as opposed to ‘industrial media’ which refers to professionally-produced radio, television, and film. (Kaplan & Haenlein, 2010; http://www.pcmag.com/encyclopedia/term/61162/social-media)
  41. 41. Web Cell phones Social Network Sites
  42. 42. Use of the Internet
  43. 43. 87%of Americans use the Internet (Fox & Rainie-Pew Report,2014)
  44. 44. (http://pewinternet.org/Infographics/2013/Health-and-Internet-2012.aspx)
  45. 45. (http://pewinternet.org/Infographics/2013/Health-and-Internet-2012.aspx)
  46. 46. (Pew Research Center, 2012)
  47. 47. FB remains dominant platform There was little room left for FB growth among teen social media users
  48. 48. Use Cell Phones & Text Messages
  49. 49. 90% of American adults have cell phones 58% have smart phones (Pew Report,2012)
  50. 50. No matter a person’s salary…. more people own cell phones than use the internet (Fox, 2013)
  51. 51. 37% have gathered health information on their phones Almost 20% have a health app (Fox, Dugan, & Purcell, 2013; Pew Report,2012)
  52. 52. Americans now spend an average of 34 hours per month using mobile apps and mobile web browsers but only 27 hours a month getting online with their PCs (Digital Consumer Report, 2013)
  53. 53. 29% of Americans own a tablet The average American owns four technology devices (Digital Consumer Report, 2013)
  54. 54. 80%send and receive text messages (Pew Report, 2012)
  55. 55. Perpetual texters … • adolescents (aged 13–17) sending or receiving 3,339 texts a month(six text per waking hour) • young adults (aged 18–24) sending or receiving 1,630 (three texts per waking hour) (Fox & Duggan, 2012)
  56. 56. (McClure, Acquanta, Harding, & Stitzer, In Press) • Survey of 8 urban drug treatment clinics in Baltimore (266 patients) • Client’s access to: - Mobile Phone 91% - Text Messaging 79% - Internet/Email/Computer 39 - 45% What do we know about clients?
  57. 57. Social Network Site … a website that provides a venue for people to share their activities with family, friends, and colleagues, or to share their interest in a particular topic. Examples include: Facebook, Google+, LinkedIn, Twitter (http://www.pcmag.com/encyclopedia/term/55316/social-networking-site)
  58. 58. SNSs are a specific type of social media that allow individuals to: • construct a public or semipublic profile within a bounded system • articulate a list of other users with whom they share a connection • view and traverse their list of connections and those made by others within the system (Boyd & Ellison, 2007)
  59. 59. Examples of Social Network Sites • Facebook • LinkedIn • Instagram • Pinterest • Virtual Worlds • Blogs • Micro Blogs-Twitter • Counselor List Serves
  60. 60. Social Networks the No. 1 U.S. social networking site 1.11billion active users 665 million users log on to Facebook in any given day May 2013 http://expandedramblings.com/index.php/resource-how-many-people-use-the-top-social-media/
  61. 61. http://expandedramblings.com/index.php/resource-how-many-people-use-the-top-social-media/ 277 million users – February 2014
  62. 62. Business Review Sites 120 million users – 53 million reviews Smith, 2014
  63. 63. YELP Review Site
  64. 64. Virtual Worlds
  65. 65. Mental health professionals are now employing virtual worlds in treating • Asperger Syndrome (Mangan, 2008) • Combat-related PTSD (Reger & Gahm, 2008; Wood et al., 2009) • Emotional Aspects of Physical Disabilities (Chen, Jeng, Fung, Doong, & Chuang, 2009)
  66. 66. BLOGS
  67. 67. tumblr http://expandedramblings.com/index.php/resource-how-many-people-use-the-top-social-media/ 216 million users – 109 million blogs
  68. 68. Micro-blogging 243 million active users http://expandedramblings.com/index.php/resource-how-many-people-use-the-top-social-media/
  69. 69. Twitter Feed
  70. 70. Counselor Listservs
  71. 71. Counselor Listservs
  72. 72. Since clients are likely to use SNSs it may be helpful for counselors/therapists to understand the phenomena of SNSs, even if they do not participate themselves. (Myers et al., 2012)
  73. 73. ETHICS & TECHNOLOGY
  74. 74. Ethical Issues • Ethical Codes and Technology • Ethics and Self Disclosure – Self Disclosure Definition/Guidelines • Self Disclosure and Social Media – Rural Examples – Guidelines for Disclosure • Ethical Reasoning • Liability Insurance for Social Media
  75. 75. Ethical Codes and Licensing Boards have not caught up with the TECHNOLOGY In some cases … provide little guidance
  76. 76. Other boards may use existing laws and investigate complaints on the grounds of: • Unprofessional conduct • Unethical conduct • Moral turpitude • Mismanagement of patient records • Revealing a privileged communication • Breach of confidentiality (Cronquist & Spector, 2011; Spector & Kappel, 2012)
  77. 77. Counselor Self Disclosure
  78. 78. Self-disclosure in psychotherapy is defined as the revelation of personal rather than professional information by a psychotherapist to a client. (Zur et al., 2009)
  79. 79. All psychologists affirm the importance of being thoughtful and intentional about how they handle issues of self disclosure. (Schwartz, 1993)
  80. 80. "All disclosures reflect decisions about the boundaries between the private self and the outer world.” (Farber, 2006)
  81. 81. Psychotherapist Self-Disclosure • Unintentional • Deliberate • Accidental • Verbal • Nonverbal • Avoidable • Unavoidable (Zur et al., 2009)
  82. 82. Counselor Self-Disclosure • BENIGN • APPROPRIATE • INAPPROPRIATE (Zur et al., 2009)
  83. 83. Technology has redefined the process of Counselor Self-Disclosure
  84. 84. “Nothing that enters cyberspace is ever completely secure” (Collins, 2007)
  85. 85. Many social network users are communicating in their virtual underwear with few inhibitions (p. 45) (Van Allen & Roberts, 2011; Rosenblum, 2006)
  86. 86. Research found that 60% of medical schools in the sample had posted unprofessional online content, including: • disclosure of patient confidentiality • profanity discriminatory language • depiction of intoxication • sexually suggestive material (Chretien & Kind, 2009)
  87. 87. Clinicians must be aware that all of their online postings, blogs, or chats may be viewed by their clients and will stay online, in some form, forever. (Zur et al., 2009)
  88. 88. Interesting professional and ethical challenges as the distinctions between private and public information blurs. (Behnke, 2008)
  89. 89. Intertwining of the Internet and clinical practice (Clinton et al., 2010)
  90. 90. Rural areas and social network sites are characterized by: • pervasive incidental contact • inevitable self-disclosure • unavoidable multiple relationships Lannin & Scott, 2013
  91. 91. 4types of rural dilemmas that involve multiple-role relationships (Schank & Skovholt, 1997)
  92. 92. Overlapping social relationships (Schank & Skovholt, 1997)
  93. 93. Overlapping Professional/Business Relationships (Schank & Skovholt, 1997)
  94. 94. overlapping relationships involving the psychologists’ family (Schank & Skovholt, 1997)
  95. 95. overlapping relationships involving the psychologists’ clients with other clients (Schank & Skovholt, 1997)
  96. 96. For example, just as transparency in rural communities may involve increased knowledge of a psychologist’s whereabouts some SNSs tag photos with exact GPS coordinates of where they were taken (Nicholson, 2011)
  97. 97. Even when a psychologist creates concrete guidelines for himself or herself around the area of self- disclosure, the Internet can potentially counteract even the best of intentions on the part of an ethical psychologist. (Zur, 2010)
  98. 98. Need to examine psychologists’ personal use of SNS outside of the therapy hour & its impact on psychologists’ reputation & credibility (Van Allen & Roberts, 2011)
  99. 99. Should counselors/therapists participate in social network sites as a private citizen?
  100. 100. (Lehavot, 2009) Certainly, we need to be thoughtful about what we post online and careful about whom we grant access to our personal information.
  101. 101. Questions to Ask Yourself Before Posting • What are the costs and benefits of posting the information? • Is there a high probability that clients will be significantly and negatively affected? • How will the disclosure affect my relationship with my clients? • Does the disclosure threaten my credibility or undermine the public’s trust in the field of counseling? (Gabbard et al., 2011)
  102. 102. Counselors Should Not POST • post client information • disparaging comments about colleagues or client groups • unprofessional media (e.g., photographs and/or videos that undercut the reputation of psychological practice) • comments about litigation in which one is involved (Gabbard et al., 2011)
  103. 103. Five Ethical Principles • Nonmalefiscence - do no harm • Autonomy-clients get to make their own choices • Beneficence-do good • Fidelity-keep promises • Justice- be fair (Kitchener, 1984; Chapin & Byrne, 2013)
  104. 104. Ethical Reasoning 1. recognize that there is an event to which to react 2. define the event as having an ethical dimension 3. decide that the ethical dimension is of sufficient significance to merit an ethics-guided response 4. take responsibility for generating an ethical solution to the problem (Sternberg, 2012)
  105. 105. Ethics Reasoning5. figure out what abstract ethical rule(s) might apply to the problem 6. decide how these abstract ethical rules actually apply to the problem so as to suggest a concrete solution 7. prepare for possible repercussions of having acted in what one considers an ethical manner; 8. act (Sternberg, 2012)
  106. 106. Legal Issues Practitioners should contact both their professional and personal liability insurance representatives to determine if professional and personal liability insurance policies cover ethical violations related to SNSs (Gabbard et al., 2011)
  107. 107. EMAILING & TEXTING PATIENTS - PRIVACY & SECURITY
  108. 108. Privacy, Security, & Confidentiality Issues
  109. 109. SO WHAT’S THE
  110. 110. “electronic exchanges”
  111. 111. Emailing Clients
  112. 112. Security of Email • Emails are stored at multiple locations: the sender's computer; your Internet Service Provider's (ISP) server; & the receiver's computer • Deleting an email from your inbox doesn't mean there aren't multiple other copies still out there • Emails are also vastly easier for employers and law enforcement to access than phone records. • Finally, due to their digital nature, they can be stored for very long periods of time
  113. 113. ‘Email is not like mailing a sealed letter or package. It’s more like sending a postcard – people are not supposed to read it while in transit, but it passes through many hands, & one can never be sure that someone is not reading it illegally.’ (AMA, 2010-13) Ms. Wendy Woods % National Frontier & Rural Reno, NV Addiction Technology Transfer Center
  114. 114. HIPAA New Rule Regarding Email • Privacy Rule allows providers to communicate electronically with patients – Reasonable safeguards • Checking email for accuracy • Sending an email alert • Limiting the amount or type of information disclosed – Must be in compliance with 45 CFR Part 164 Subpart C • Health care providers can provide email reminders to patients if they consent • Patients can initiate email communications with providers using email
  115. 115. Re-Targeting
  116. 116. Do you or your staff TEXT clients?
  117. 117. More than one-third of cell phone users (http://www.saurageresearch.com/key-findings-novemberdecember-2009/) • have sent a text message to the wrong person (38%) • report that a text they sent was misunderstood by the reader (37%)
  118. 118. TEXTING Miscommunications
  119. 119. Text Messages can be saved, sent to an email account, and posted online all without the other person’s permission
  120. 120. Confidentiality
  121. 121. Text Message Transmission Process
  122. 122. “Traditional Short Message Service (SMS) text messaging is non-secure and non- compliant with safety and privacy regulations under the HIPAA. Messages containing ePHI can be read by anyone, forwarded to anyone, remain unencrypted on telecommunication providers’ servers, and stay forever on sender’s and receiver’s phones.” (American Academy of Orthopaedic Surgeons, August 2012)
  123. 123. “No it is not acceptable for physicians or licensed independent practitioners to text orders for patients to the hospital or other healthcare setting. This method provides no ability to verify the identity of the person sending the text and there is no way to keep the original message as validation of what is entered into the medical record.” The Joint Commission November 10, 2011 http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFaqId=401&ProgramId=1
  124. 124. To ensure the patient’s privacy clinicians should consider the use of encrypted email systems or portal messaging systems that can be used by a computer, tablet, or smart phone MESSAGING
  125. 125. Safe Practices
  126. 126. maintain physical control of your mobile device/computer (http://www.HealthIT.gov/mobiledevices)
  127. 127. unsecured networks (http://www.HealthIT.gov/mobiledevices)
  128. 128. unintentional disclosure (http://www.HealthIT.gov/mobiledevices)
  129. 129. check out what is downloaded on your mobile device/computer and keep the security software updated (http://www.HealthIT.gov/mobiledevices)
  130. 130. activate wiping and/or remote disabling (http://www.HealthIT.gov/mobiledevices)
  131. 131. use a secure portal to send or receive PHI over public Wi-Fi networks(http://www.HealthIT.gov/mobiledevices)
  132. 132. Implement policies & procedures to restrict access to, protect the integrity of, & guard against unauthorized access to electronic PHI (e-PHI) (HHS Office for Civil Rights)
  133. 133. Do you or your agency have a social media policy?
  134. 134. SOCIAL MEDIA POLICY ISSUES
  135. 135. For Clients and/or Staff?
  136. 136. Whether the counselor accepts friend requests from social networking sites (Kaplan, Wade, Conteh, & Martz, 2011)© Keely Kolmes, Psy.D. – Social Media Policy – 4/26/10
  137. 137. If a client friends you and you accept them, they have access to your pictures Halloween Party 2012
  138. 138. Whether clients can be a Facebook friend of the counselor (Kaplan, Wade, Conteh, & Martz, 2011)© Keely Kolmes, Psy.D. – Social Media Policy – 4/26/10
  139. 139. LIKING
  140. 140. Whether clients may be a follower of the counselor on Twitter (Kaplan, Wade, Conteh, & Martz, 2011)© Keely Kolmes, Psy.D. – Social Media Policy – 4/26/10
  141. 141. Our opinion is that engaging in friending and following those whom we serve, supervise, teach, or collect research data from, crosses appropriate boundary lines because it implies a personal relationship (Kaplan, Wade, Conteh, & Martz, 2011)
  142. 142. (Zur, 2010) Whether clients can text, email, or take phone calls during sessions?
  143. 143. Sometimes use of technology in session provides counselor/therapist with greater insight (Zur, 2010)
  144. 144. (Kaplan, Wade, Conteh, & Martz, 2011)© Keely Kolmes, Psy.D. – Social Media Policy – 4/26/10 Whether you utilize listservs for online consultations
  145. 145. Online Consultations
  146. 146. increase the possibility of inadequate and simplistic solutions being offered Kaslow, Patterson, & Gottlieb, 2011 ONLINE Consultations (Kaslow, Patterson, & Gottlieb, 2011)
  147. 147. risk of violating client confidentiality unless identifying information is well camouflaged Kaslow, Patterson, & Gottlieb, 2011 ONLINE Consultations (Kaslow, Patterson, & Gottlieb, 2011)
  148. 148. Unless the person seeking consultation knows the counselor who is responding, he or she has no assurance about the efficacy, accuracy, validity, and soundness of the information provided (Kaslow, Patterson, & Gottlieb, 2011)
  149. 149. Whether messaging through social network sites such as Linkedln or Facebook can be used to interact with the counselor (Kaplan, Wade, Conteh, & Martz, 2011)© Keely Kolmes, Psy.D. – Social Media Policy – 4/26/10
  150. 150. FACEBOOK CHAT
  151. 151. “Clients should know that electronic communications are generally not secure methods of communication and there is a risk that one's privacy/confidentiality could be compromised with their use" (Neace , 2011)
  152. 152. The conditions under which Google, Facebook, or other search engines may be used to find out information about a client (Kaplan, Wade, Conteh, & Martz, 2011)© Keely Kolmes, Psy.D. – Social Media Policy – 4/26/10
  153. 153. The accessibility, anonymity, and universality of the Internet have made it easier and more tempting to “Google” clients
  154. 154. Prevalence of Googling • 22% of 193 clinical psychology graduate students had Googled their psychotherapy clients (Martin, 2010) • 28% of 227 multidisciplinary psychotherapists accidentally found information about clients online whereas 48% intentionally sought this information (Kolmes & Taube, 2010)
  155. 155. • 98% of doctoral psychology students had searched for at least one client’s information over the past year… even though most reported that searching for clients online was “always” or “usually” unacceptable. (DiLillo & Gale, 2011)
  156. 156. Is it infringing on a patient’s privacy? Patient Targeted Googling …
  157. 157. Would it be okay for a counselor to drive by a clients’ house?
  158. 158. 33 Things to Consider Before Conducting Patient Targeted Googling • consider the intention of the search • evaluate the potential risk to the patient • anticipate the effect of gaining previously unknown information
  159. 159. More in depth questions 1. Why do I want to conduct this search? 2. Would my search advance or compromise the treatment? 3. Should I obtain informed consent from the patient prior to searching? (Clinton, Silverman, & Brendel, 2010)
  160. 160. 4. Should I share the results of the search with the patient? 5. Should I document the findings of the search in the medical record? 6. How do I monitor my motivations and the ongoing risk-benefit profile of searching? More in depth questions (Clinton, Silverman, & Brendel, 2010)
  161. 161. On the other hand
  162. 162. With the click of a mouse, clients can find a wealth of information on their counselors about their psychologists online (Tunick, Mednick, & Conroy, 2011)
  163. 163. Some personal information about the clinician may be available to the client without the psychotherapist’s knowledge or approval (Lannin & Scott, 2013)
  164. 164. In some cases psychologists in training had either been matched with current/former clients through anonymous dating websites (Taylor et al., 2010)
  165. 165. Clients Googling Counselors 70% of clients reported finding personal information about their psychotherapist on the Internet only 28% discussed it with their psychotherapist (Kolmes & Taube, 2011)
  166. 166. How do you respond if a client tells you that he has “Googled” you or visited your website?
  167. 167. Whether the counselor accepts testimonials on his or her various websites (Kaplan, Wade, Conteh, & Martz, 2011)© Keely Kolmes, Psy.D. – Social Media Policy – 4/26/10
  168. 168. The American Psychological Association’s Ethics Code states under Principle 5.05 that it is unethical for psychologists to solicit testimonials: “Psychologists do not solicit testimonials from current therapy clients/patients or other persons who because of their particular circumstances are vulnerable to undue influence.”
  169. 169. How the counselor may or may not respond to comments or ratings posted on internet sites (Kaplan, Wade, Conteh, & Martz, 2011)© Keely Kolmes, Psy.D. – Social Media Policy – 4/26/10
  170. 170. How the counselor notifies clients regarding GPS Notification Services (Kaplan, Wade, Conteh, & Martz, 2011)© Keely Kolmes, Psy.D. – Social Media Policy – 4/26/10
  171. 171. Confidentiality Issues… (Kaplan, Wade, Conteh, & Martz, 2011)© Keely Kolmes, Psy.D. – Social Media Policy – 4/26/10
  172. 172. If the organization has a social media policy?
  173. 173. Employees will share their gripes and struggles on Twitter, Facebook, YouTube, Instagram, and any other site with friends or strangers who will listen…… (Kasarjian, 2013)
  174. 174. The NLRA is not just about unions and collective bargaining…. This right extends to communications with co-employees as well as third parties “concerted activities” protected by Section 7 right to communicate about wages, hours, and other terms and conditions (Morrison & Foerster, 2014)
  175. 175. National Labor Relations Act • Employers should still exercise considerable caution when responding to complaints about an employee’s use of social media • An employee’s comments on social media are generally not protected if they are mere gripes not made in relation to group activity among employees • Postings that are otherwise protected by the NLRA are unlikely to lose that protection merely because they are offensive, even if they use profanity (Morrison & Foerster, 2014)
  176. 176. The key that NLRB or judges try to determine is if an employee is griping (complaining) for their own self interest or on behalf of co-workers. Protected concerted activity includes discussions and these do not have to be formalized events (Zywave Inc., 2012)
  177. 177. When employees are reprimanded or terminated for statements they make online the unwary employer may find that it has inadvertently entered an area that is a hotbed for scrutiny and litigation. (Kasarjian, 2013)
  178. 178. 2 Facebook Examples (Morrison & Foerster, 2014)
  179. 179. Be careful with staff social media policy Why don’t I draft a policy about this? (Kasarjian, 2013)
  180. 180. Social Media Policy Sample • Use Sample Policy Based upon Walmart’s Policy • Use examples • Don’t use a summary statement that this policy doesn’t violate employees’ Section 7 Rights • Many case examples - don’t become one of them (Kasarjian, 2013)
  181. 181. 2Additional Issues
  182. 182. DON’T EVER ‘SHOULDER SURF’ or MAKE AN EMPLOYEE SHARE THEIR PASSWORD or ASK THEM to ‘FRIEND YOU’ (Klemchuk & Desai, 2014)
  183. 183. 10states … Arkansas, Colorado, Illinois, Nevada, New Jersey, New Mexico, Oregon, Utah, Vermont and Washington … enacted legislation in 2013 (Vermont's legislation provides for a study only) 28 states- legislation pending http://www.ncsl.org/research/telecommunications-and-information-technology/employer-access-to-social-media-passwords-2013.aspx
  184. 184. In a recent survey (2012) by CareerBuilder… approximately 37%of companies indicated they use social networking sites to research job candidates www.careerbuilder.com/share/aboutus/pressreleasesdetail.aspx?id=pr691&sd=4%2f18%2f2012&ed=4%2f18%2f2099
  185. 185. Companies need to be careful when using social media in recruiting employees and researching applicants ‘What is learned cannot be unlearned’ Protected Class (race, religion, & disability) (Kasarjian, 2013)
  186. 186. CLINICAL SUPERVISION & TECHNOLOGY
  187. 187. Clinical Supervisors & Technology: A Balancing Act
  188. 188. Counselor supervision is … “the means by which skills are refined, theory and practice are integrated, and trainees explore their new professional identities in preparation for induction into their profession” (pp. 242–243) (Dollarhide & Miller, 2006)
  189. 189. Counselors may avoid seeking guidance on social network/internet/technology issues because of a perceived lack of supervisor knowledge (Lannin & Scott, 2013)
  190. 190. Importance of Supervisors Conducting Self Assessments
  191. 191. Clinical Supervisors… Have you asked your supervisees if they email or text clients?
  192. 192. Technology could create a threat to usual patterns of supervision
  193. 193. Accessible easy to approach & speak freely
  194. 194. Clinical Supervisors may provide face-to-face supervision, online supervision, or a hybrid of online and face-to-face approaches.
  195. 195. Computer-based Clinical Supervision (a) lower costs to supervisees (b) increased flexibility in scheduling (c) greater cost-effectiveness for educational institutions (d) provision of supervision opportunities for those who live in rural areas (e) increased diversity of counselor trainees based on increased accessibility (Bloom & Walz, 2000)
  196. 196. Online Clinical Supervision • Online supervision should occur through encrypted channels • More investigation is needed into the process of distance-based supervision and its effects on supervision quality (Vaccaro &Lambie 2007)
  197. 197. HIPAA Compliant
  198. 198. Training Substance Abuse Clinicians in Motivational Interviewing (MI) using live supervision via teleconferencing Teleconferencing supervision (TCS) was developed to provide remote, live supervision for training MI (Smith et al., 2012)
  199. 199. Supervisors should consider all the same issues relevant to counselors and their clients when considering sharing personal information online with: 1. supervisees 2. accessing supervisees’ information online 3. communicating through social networking sites with supervisees
  200. 200. Questions
  201. 201. ‘Ethical behavior does not arise solely from habit or obedience to patterns or rules but includes intelligently guiding our actions in harmony with the texture of the situation’ (Luce-Kapler, Sumara, & Iftody, 2010, p. 540)

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