Exploring the practice and attitudes of psychiatrists and psychologists towards patient-targeted googling in China

Background: Patient-targeted Googling (PTG) is an unavoidable aspect of the internet era, offering both opportunities and risks. However, no PTG studies have been conducted in Asian contexts to date. Additionally, existing research has provided limited exploration of factors influencing PTG practices, particularly regarding the professional differences between psychiatrists and psychologists. This study seeks to address these research gaps.

Method: A total of 943 licensed psychiatrists and psychologists working in China completed an online survey. The survey included their attitudes towards PTG (including general attitude, application situations, reasons for/against PTG) and their actual practice of PTG.

Results: 250(26.5%) respondents reported using PTG. Among them, 151(60.4%) respondents sought consent from clients before use, and 142(56.8%) respondents discussed search results with clients after use. Chinese psychiatrists and psychologists have contradictory attitudes, with concerns but also recognition of its possible positive effects, and expressing a need for more guidance. Compared to psychiatrists or those working in public institutions, psychologists and those working in private institutions report greater concerns about PTG but engage in it more frequently.

Conclusions: Although the sample is limited, the study reveals notable differences in attitudes and practice of PTG among Chinese psychiatrists and psychologists, which may be related to their distinct professional roles and workplace environments. These findings suggest the need for further research to better understand the underlying factors contributing to these differences. Moreover, the results highlight the importance of developing tailored ethical guidelines and targeted training programs to address PTG practices for psychiatrists and psychologists in China.

1 Introduction

Patient Targeted Googling (PTG) refers to the practice of mental health professionals obtaining client information through online channels. This concept originated in Clinton, Silverman, and Brendel (1), where Google, the most popular search engine at that time, was used to refer to online searching behavior (2). Currently, PTG can be completed through various search engines and social media (3, 4). In fact, social media has become a part of people’s daily life, and individual information is more easily retrieved by others (5). The content published by users on these platforms, and even their browsing traces, can be obtained by others, which exposes the living habits and attitude preferences of people (6, 7).

The opportunities and risks of PTG have been extensively discussed and investigated in mental health care. On the positive side, PTG provides can enhance clinician’s understanding of patient, help identify risks and facilitate timely interventions (8–12). However, PTG also raises concerns, including potential harm to the therapeutic relationship, privacy violations, and the risk of being misled by inaccurate online information (9, 11–13). Given these complexities, it is crucial to examine the appropriateness of PTG in clinical practice and develop guidelines for its appropriate use.

Research on PTG has predominantly focused on psychologists and psychiatrists, with significant variation in reported usage rates. Among psychologists, the lowest reported rate of PTG use was 25.6% in a 2014 study from the United States (14), while the highest was 97.8% in a 2011 study conducted in the United States and Canada (14). Other studies have reported PTG rates ranging from 40% to 85% (9, 15–17). In contrast, research on PTG among psychiatrists is sparse, with one U.S. study from 2013 reporting a 35% usage rate (18). In combined samples of psychiatrists and psychologists, a 2018 study in New Zealand found that 53.4% of participants engaged in PTG (12).

On this basis, there has been relatively little research on the factors influencing PTG practices and attitudes. Among these, professional experience has been the most frequently examined, but the results remain inconsistent. Some studies have found that the more experienced psychologists are, the more lenient their attitudes toward PTG become (14, 16), though their actual practice of PTG decreases (14). In contrast, studies involving mixed samples of psychologists and psychiatrists have yielded divergent findings: a study have found that professional experience negatively predicts PTG usage (8), while the other one have found no relationship between experience, age, and PTG practices (12). Exploration of other influencing factors is almost nonexistent.

These findings provide three key insights. First, there are significant variations in the epidemiological data on PTG, suggesting that regional and temporal differences may influence PTG practices. Second, there appear to be distinctions in PTG usage between psychologists and psychiatrists. Unfortunately, no studies have directly investigated these differences, which could help us better understand the specific clinical value and risks of PTG. However, given the differences in their training and clinical approaches (19) and the data above, it is hypothesized that these two groups may have distinct perspectives on PTG. Finally, there has been limited exploration of the factors influencing PTG usage, and the results have been inconsistent while further investigation into these factors could provide better guidance for PTG practices.

In China, the rapid expansion of the internet has had a profound impact on various sectors, including mental health services. As of June 2022, there were over 1.051 billion internet users in China, with 1.027 billion social medical users (20). In such a digital milieu, it is conceivable that a considerable prevalence of PTG might be observed among psychiatrists and psychologists in China (15, 21). The use of online healthcare has seen significant growth, particularly following the Covid-19 pandemic (22, 23). In this digital environment, it is likely that PTG is becoming increasingly prevalent among Chinese psychiatrists and psychologists.

Based on the aforementioned background, this study will investigate the attitudes and practices related to PTG among Chinese psychiatrists and psychologists. The study aims to (1): provide the first set of data from Asia on PTG attitudes and practices, exploring potential cultural differences; and (2) examine the potential impact of common demographic and occupational factors on PTG attitudes and usage. A key focus of the study will be the comparison between psychiatrists and psychologists.

2 Materials and methods

2.1 Participants and procedure

The research sample for this study consisted of licensed psychiatrists, psychotherapists and psychological counselors in China. According to the Mental Health Law of China (24), psychotherapist is a qualified practitioner who can provide psychotherapy for mental disorder clients in medical institutions, while psychological counselors can only provide psychological counseling to clients in non-medical institutions such as social counseling institutions, community, schools, and other enterprises (25). Both of them can be referred to as “psychologists”, and neither of them have the right to make mental disorder diagnose or prescribe medications. Participants could have multiple identities simultaneously (like being licensed as both a psychiatrist and a psychotherapist), but the questionnaire allowed them to self-select only the one with which they most identified.

The study used an online questionnaire survey to collect data from the sample. The questionnaire was created on through an online platform powered by www.wjx.cn and shared with members of the Chinese Psychiatrist Association and the China Association for Mental Health through WeChat groups. The questionnaire was shared under the title “Online Mental Health Service Survey” to reduce respondent interest bias. The survey was conducted from April 10, 2022, to October 5, 2022. The researchers also invited members of these associations to complete the online survey and share the link with other psychologists and psychiatrists in their network. All participants were asked to answer basic demographic questions and questions related to their attitudes and practices towards PTG. A quality control question was interspersed throughout the survey to ensure data quality.

A total of 982 psychologists and psychiatrists completed the online questionnaire survey. After screening, the final analysis included 943 questionnaires, including 422 psychiatrists, 106 psychotherapists and 415 psychological counselors.

2.2 Questionnaire

The questionnaire consisted of three sections: personal demographic and occupational information, PTG practices, and attitudes toward PTG. The concept of PTG was explained at the outset to ensure participants had a clear understanding (1, 3).

The first section gathered demographic and occupational information, including gender, age, occupation (psychiatrist/psychotherapist/psychological counselor), highest educational level (doctor/master/undergraduate/other), years of service, primary workplace (public/private institution), and whether participants provided online mental health services.

To reduce social desirability bias, questions related to PTG practices were presented first, including whether participants had ever used PTG and whether they informed patients before or after its use.

The subsequent section focused on participants’ attitudes towards PTG, covering four key aspects: general attitudes, applicable situations, reasons for supporting PTG, and reasons against PTG. General attitudes were assessed through five items, including concerns about PTG, perceptions of PTG’s applicability in daily practice, views on the positive role of PTG in treatment or counseling, whether participants had received adequate guidance on PTG, and their desire for more explicit PTG guidelines. Responses were measured on a 7-point Likert scale (7 = fully applicable, 1 = not applicable). The section on PTG applications included seven common situations in which PTG might be used, and participants were asked to indicate their approval or disapproval of PTG in these contexts. The final section listed nine common reasons for supporting PTG and seven reasons for opposing it. Participants were asked to express their agreement or disagreement with these reasons.

Specific items investigating PTG attitudes and practices are detailed in Figure 1. All items were based on Cox’s systematic review (10) and three empirical studies were highlighted (9, 12, 26). The questionnaire was reviewed by a senior psychiatrist and a senior psychotherapist to ensure its relevance and feasibility within both professional and Chinese cultural contexts.

Figure 1

Figure 1. Specific items of the questionnaire.

2.3 Statistical methods

The raw data was analyzed by SPSS 26.0. The frequencies and means of the demographic variables of the study were first calculated by descriptive statistics. Data were presented as means ± standard deviations.

The main statistical methods used were chi-square tests t-tests, and analysis of variance to compare the differences in the attitudes and practices of the participants in the different groups. Logistic regression analysis was used to test factors that may affect individuals’ PTG practices.

2.4 Ethical considerations

This study was approved by the Ethics Committee of the Shanghai Mental Health Center (IORG0002202, FWA00003065). The purpose of the study and informed consent were explained on the questionnaire homepage, and a consent form was presented before the survey began. The consent form explained that the study invited psychologists and psychiatrists to provide objective feedback on their working experience, including demographic information and attitudes towards PTG, and practices of PTG. Participants were given the choice to either agree or refuse to participate and could withdraw from the study at any time. Only participates who clicked the “agree” button could enter the formal questionnaire page to finish the survey. If participates felt uncomfortable during the survey, they could choose to end the survey and exit.

3 Results

3.1 Demographic characteristics of the participants

A total of 982 psychologists and psychiatrists completed the questionnaire, and 943 participants passed the quality control question, which consisted of 422 psychiatrists, 106 psychotherapists, and 415 psychological counselors. Since there were no significant differences found between psychotherapists and counselors in almost all items, they were grouped together under the label “psychologists” to enhance the brevity of the results without compromising accuracy. The detailed data of psychotherapists and counselors can be found in Appendix 1 in Supplementary Material.

The average age of participants was 40 years, with no significant difference between psychiatrists and psychologists. The average service years for participants was 8.6 years, with psychiatrists (M = 10.58) reporting significantly longer service years than psychologists (M = 7.00). The overall sample had a higher proportion of female participants (68.7%), a characteristic that was more pronounced among psychologists (76.6%). Participants’ highest educational attainment was primarily concentrated at the undergraduate (55.8%) and master’s levels (34.7%). Among psychiatrists, a greater proportion held a bachelor’s degree (61.4%) and a doctorate (12.8%) compared to psychologists (51.2% and 3.5%, respectively), while the proportion of those holding a master’s degree was lower among psychiatrists (24.9%) than psychologists (42.6%). The majority of participants worked in public institutions (68.0%). Almost all psychiatrists were employed in public institutions (95.0%), whereas psychologists were more evenly distributed between public (46.1%) and private institutions (53.9%). Lastly, 71.3% of the overall sample reported providing online mental health services, with a lower percentage among psychiatrists (51.7%) compared to psychologists (87.1%). Detailed information is presented in Table 1.

Table 1

Table 1. Basic information of the participants.

3.2 Practice of PTG

The PTG practices of participants across different groups are detailed in Table 2. The overall reported use of PTG in the sample was 25.6%, with a higher proportion of psychologists (34.9%) reporting PTG use compared to psychiatrists (16.1%). Additionally, younger participants (vs. older participants), those with fewer years of service (vs. those with more years of service), those working in private institutions (vs. public institutions), and those providing online services (vs. those not providing online services) reported significantly higher rates of PTG usage.

Table 2

Table 2. Positive response rate of PTG practice in different groups (%).

Among participants who had used PTG, 60.4% indicated that they sought client consent before using PTG, and 56.8% reported discussing the search results with their clients afterward. The proportion of participants seeking consent was lower among those with doctoral degrees compared to those with lower levels of education, while the proportion of participants discussing results was lower among those working in private institutions compared to those in public institutions. No statistically significant differences were found in these two items across other groups.

3.3 Attitudes towards PTG

Table 3 reports participants’ general attitudes towards PTG. Overall, participants expressed concerns about the use of PTG (M = 3.109) and generally disapproved of its routine use (M = 3.716). However, their attitudes toward the positive role of PTG in treatment or counseling were neutral (M = 4.028). Participants reported receiving limited guidance on PTG (M = 2.374) but expressed a desire for more formal training or courses on the subject (M = 5.139). Comparisons between different groups revealed that psychiatrists had a more positive general attitude toward PTG compared to psychologists, men were generally more positive than women, those with postgraduate m degrees (master’s or doctorate) were more positive than those with undergraduate degrees, participants working in public institutions had a more positive attitude than those in private institutions, and those who did not provide online mental health services had a more positive attitude than those who did. Participants who practiced PTG were more likely than those who did not to believe in the positive role of PTG in treatment or counseling, perceived that they received more guidance, and had fewer concerns about PTG.

Table 3

Table 3. General attitudes towards PTG in different groups.

Regarding the appropriate use of PTG, participants largely agreed that PTG is acceptable “when there is a danger to oneself or others” (83.5%), “when requested or desired by clients” (57.1%), and “when more information is needed” (50.6%). However, very few participants supported the use of PTG “when driven by mere curiosity” (8.1%). There were differences in attitudes between groups. In situations such as “when requested by clients,” “when more information is needed,” and “when there are issues with psychological services,” psychiatrists (vs. psychologists), public institution workers (vs. private institution workers), and those who do not provide online services (vs. those who provide) showed higher approval rates. Additionally, participants working in public institutions and those who do not provide online services showed higher approval rates in situations such as “when the client is a public figure” and “when the content of therapy involves suspicion of cyberbullying.” Detailed differences in participants’ attitudes toward common PTG situations are presented in Table 4.

Table 4

Table 4. Positive response rate of appropriate situations of PTG in different groups (%).

Participants generally supported PTG for reasons such as “risk reduction” (78.6%), “screening function” (54.7%), and “better understanding of clients” (51.4%). Differences in support for PTG across various participant groups were observed. Specifically, participants who did not provide online services expressed higher support across eight of the reasons, while psychiatrists and those working in public institutions showed higher support across seven reasons. Additionally, men expressed higher support across four reasons. Differences among the other groups were less pronounced. Detailed agreement rates for supporting reasons across different groups are presented in Table 5.

Table 5

Table 5. Positive response rate of reasons for PTG in different groups (%).

In terms of opposition to PTG, participants generally believed that PTG could “violate boundaries/privacy” (78.0%), “disrupt the therapeutic alliance” (73.4%), “threaten client autonomy and control of information” (66.1%), “lead to manipulation/lack of impartiality” (59.2%), and “limit curiosity” (51.5%). Compared to supporting reasons, there were fewer differences between participant groups regarding opposition to PTG. However, private institution workers expressed higher agreement rates across five items, and women expressed higher agreement rates across four items. Differences among the other groups were minimal. Detailed attitudes toward reasons for opposing PTG are presented in Table 6. It is worth adding that the results also found a significant positive correlation between the number of pro-and anti-PTG opinions identified by the participants (r=0.232, p<0.01).

Table 6

Table 6. Positive response rate of reasons against PTG in different groups (%).

At last, a binary logistic regression analysis was conducted using participants’ demographic and attitude variables as independent variables and PTG usage as the dependent variable. The forward: LR method was used for variable selection. The final model included the following variables: psychologists (reference category: psychiatrists, B = 0.873, OR = 2.395), private institution (reference category: public institution, B = 0.762, OR = 2.143), and age (B = -0.036, OR = 0.964) among demographic factors; having received full instruction on PTG (B = 0.277, OR = 1.319) among general attitude factors; and the belief that PTG provides a better understanding of clients (B = 0.457, OR = 1.579) among supporting reasons. The Nagelkerke R² for the model was 0.158, and the results of the Hosmer-Lemeshow test indicated a chi-square value of 5.382 (p = 0.716), suggesting that the model had a good fit (Table 7).

Table 7

Table 7. Binary logistic regression analysis results of PTG Practice.

4 Discussion

4.1 Prevalence of PTG in China

This study presents the first set of data in the Asia (China) for PTG research. Firstly, regarding the attitudes towards PTG, the results of this survey are consistent with previous studies in Western countries (14, 26–29). Overall, Chinese psychologists and psychiatrists have concerns about PTG and hope to receive more guidance (9, 30). Although the benefits and risks of PTG vary in specific situations, PTG behavior driven by curiosity is generally resisted (9, 10). In fact, these results are also in line with the General Principles in the American Psychological Association (APA) Ethical Principles of Psychologists and Code of Conduct (13, 31) and previous PTG practice recommendations (32).

However, the actual use of PTG by Chinese psychiatrists and psychologists is relatively low. In this survey, only 26.5% of participants reported having used PTG, a figure significantly lower than the 53.4% reported in New Zealand in 2018 among psychiatrists and clinical psychologists (12). When examined separately, the practice rates of PTG among both psychiatrists and psychologists in this study were also lower than the usage rates reported in similar single-sample studies within the past five years (15–17, 32). Surprisingly, among those who did use PTG, the proportion of individuals who obtained client consent before conducting PTG (60.38%) and the proportion who discussed the search results with the client afterward (56.98%) were much higher than the 16% to 40% reported in the systematic review by Cox (10).

We suggest that the lower prevalence of PTG in China may be associated with the cautious attitude of Chinese people towards self-disclosure on social networking sites (33). Previous research has consistently found that East Asians, including Chinese individuals, tend to express less self-sensitive information than Westerners (34, 35). Despite some concerns about privacy, Americans are generally more comfortable with sharing personal information online, as they perceive more benefits and lower risks from social network activities and have greater trust in service providers and legal protections (36, 37). Chinese people tend to be more reserved in their self-expression on social networking sites, and this attitude may also affect their perception of online information quality and reliability, leading to a lower likelihood of PTG. Additionally, China has a lower number of mental health practitioners per capita than the United States, which could result in more workload and pressure on Chinese psychologists and psychiatrists (38). As a result, they may prefer to use effective and rapid information collection methods, such as direct questioning of parents (39), rather than PTG.

4.2 Differences between attitudes and practices

This study revealed three notable and significant patterns: psychologists (vs. psychiatrists), those working in private institutions (vs. public institutions), and individuals providing online services (vs. not providing online services) expressed greater concerns about PTG but also demonstrated a higher reliance on its use in practice.

For psychologists, this may be linked to their emphasis on the therapeutic alliance. “Disrupting the therapeutic alliance/impacting trust” is one of the primary reasons many professionals oppose PTG. The therapeutic alliance is a critical element of psychotherapy (40, 41), often directly influencing the success or failure of treatment (42, 43). In contrast, psychiatrists primarily rely on medication as a treatment modality, and the therapeutic alliance is relatively less significant for medication efficacy (44, 45). This distinction makes psychologists more cautious about the potential negative impacts of PTG. Additionally, psychologists are more involved in processes such as transference and empathy, making them more sensitive to ethical concerns like privacy and justice (46, 47).

But surprisingly, despite the presence of more concerns, psychologists gave more practice to PTG. This may be due to differences in their working resources. Psychiatrists often rely on a variety of objective sources, such as blood tests, symptom scales, family observations and so on, to formulate diagnoses and treatment plans with a well-rounded view. In this case, the benefits of PTG practice may not seem necessary. In contrast, psychologists depend heavily on the subjective information provided by clients during therapy sessions (48, 49). It is challenging for novice therapists to navigate, extract, and make sense of the information reported by patients, prompting them to seek additional data through PTG. Moreover, research indicates that few participants have fully considered the potential risks of PTG before engaging in it (50), suggesting that situational factors play a significant role in this behavior. Psychologists, in particular, tend to spend more time with individual cases—for example, seeing 2 to 3 clients in a morning session, compared to psychiatrists who may see over 10 patients in the same timeframe (19). This gives psychologists more opportunities to conduct PTG searches. Additionally, the covert nature of PTG, being largely anonymous and private, may reduce perceived risks, leading psychologists to engage in PTG despite their concerns. A large-scale study conducted in the United States on psychology doctoral students found that two-thirds of participants, despite disapproving of PTG, had used it at least once. The study attributed this to the frequent use of the internet by graduate students (14).

A similar pattern was observed among participants working in private institutions. They expressed more negative attitudes towards PTG compared to their counterparts in public institutions, reported higher usage rates. One of the important reasons may be that psychologists are the main service members in private institutions, and there are few psychiatrists. However, after the occupational difference is included in the regression equation, the prediction function of private institutions is still significant, which shows that its unique aspects have not been explained. The characteristics of clients in private institutions may be a contributing factor. Private institutions generally have fewer clients than public institutions (25, 51), and their clients often have higher expectations for service quality (52). A studies have found that high patient concerns about privacy predict negative perceptions of PTG (53), and privacy issues are important reasons for many clients to choose more expensive private institutions. This drives professionals to be more cautious in their practice to avoid negative experiences that could lead to client loss. However, the covert nature of PTG may allow private institution staff to engage in it despite their concerns. Additionally, many private institutions that emerged during the current mental health boom are registered with local business bureaus rather than health authorities, and a significant number of their staff may lack formal degrees in psychiatry or psychology (25, 54), resulting in weaker awareness of ethical issues. The focus on attracting clients in private institutions, where social media and search engine advertising are common strategies (30), may also make PTG use more instinctive.

Finally, the differences in attitudes and practices among those providing online services may be due to the overlap with the characteristics of psychologists and those working in private institutions. The logistic regression analysis showed that psychologists (OR=4.380, p<0.01) and private institution staff (OR=4.740, p<0.01) were the strongest predictors for providing online services. And in the regression model predicting PTG usage, “providing online services” was not included in the equation, yet psychologists and private institution staff still demonstrated significant predictive power.

4.3 Predictors of PTG practice

The logistic regression results showed that professional background and workplace were the strongest predictors of PTG use among the demographic variables. This was followed by whether participants had received sufficient PTG guidance (as part of general attitudes) and the belief that PTG could help in better understanding clients (as part of supporting attitudes). Although age had a statistically significant effect, its influence was relatively weak. Gender, service years and whether online service did not affect PTG usage.

The impact of professional background and workplace on PTG practice has been discussed in detail in previous sections. Regarding attitudes, it is not surprising that recognizing PTG as a way to obtain more comprehensive information, which can promote understanding and empathy towards clients, serves as a predictor of PTG use. The core purpose of PTG is to gather more information about clients (55). If practitioners believe that this additional information will benefit their clients, they are more likely to engage in PTG. Furthermore, adequate guidance can help individuals better understand the concept and methods of PTG, increasing their confidence in using it (56).

However, it is essential to consider whether the additional information provided by PTG truly contributes to a better understanding of the client, or if it merely reflects a reliance on external information due to a lack of experience. PTG can be seen as a shift from “analysis” to “action (17),” which makes the problem less challenging but also hinders the development of the therapist’s professional competence. From another perspective, search may also be evidence that the therapeutic alliance is not yet stable (57). In fact, some studies have found correlations between more experience and less search frequency (8, 14). For senior psychodynamic therapists, the fantasies described by patients is even more valuable than the actual reality (17, 50). Therefore, both psychiatrists and psychotherapists should be cautious about relying on PTG, as overreliance may hinder the development of professional skills.

In addition, the study found that age had a significant, albeit weak, effect on PTG use, with younger professionals being more likely to engage in PTG. This may be because younger individuals, as digital natives, are more familiar with and reliant on the internet (30). However, the average age of participants in this study was 40, which is not particularly old, and many professionals have started providing online treatment during the pandemic, making them also familiar with internet usage. Therefore, the influence of age on PTG practice is not as pronounced.

Last but not least, professional experience is often thought to influence practitioners’ PTG practices. However, in both the group comparisons of attitude items and the final regression model of PTG practice, the impact of professional experience was not confirmed. While the use of years of service as a proxy for professional experience in this study may not have been entirely accurate, a similar study conducted with a mixed sample of psychiatrists and psychotherapists in New Zealand reported comparable results (12). Therefore, further validation of this relationship is needed in future research.

4.4 Contradiction between support and opposition

Beyond the differences in attitudes and practices, the study also revealed a positive correlation between the number of reasons participants endorsed for supporting PTG and those for opposing it. This suggests an internal conflict among participants regarding PTG, which is understandable given the clear potential risks and benefits of PTG. Existing literature has extensively discussed the potential risks and benefits of PTG, such as whether PTG violates client privacy, disrupts the therapeutic relationship, or impacts treatment outcomes (10, 17, 29). On the other hand, completely rejecting PTG might result in missed opportunities for deeper understanding and timely intervention for patients (3, 11). With the increasing prevalence of digitalization and the refinement of social media algorithms, psychiatrists and Psychologists may face more situations requiring PTG decisions, sometimes even involuntarily (e.g., client profiles being suggested on social media platforms).

Unfortunately, the study indicates that psychiatrists and psychologists have received very limited guidance on PTG (58), despite expressing a strong need for it. Therefore, providing clear guidelines and instructional materials on whether and how to use PTG is crucial. Cole (59), in a review of PTG literature, recommended that decisions about PTG should always be based on the patient’s specific circumstances and should prioritize the “best interests of the patient.” The risk-benefit framework can be used to assess the necessity and impact of PTG, guiding professionals in conducting ethically permissible searches while considering the intrusiveness of PTG and its potential impact on the therapeutic relationship (1, 59).

If PTG is deemed necessary, obtaining the client’s consent in advance may be a better approach. This would not only ensure the accuracy of the information gathered but might also strengthen the therapeutic alliance by demonstrating the therapist’s concern for the patient (50). If the client refuses, the professional can gain further insight into the patient through the act of refusal and discussions around it.

4.5 Limitations

Despite efforts to refine it, this study still has some limitations. Due to the limitation of objective factors, the study did not conduct focus group discussions during the design of the questionnaire, which may lead to limitations in the applicability and diversity of the questionnaire. In addition, the collection of professional experience in the questionnaire depends on the years of practice reported by the participants, but the years and experience may not be exactly matched. For example, a psychologist with ten years of experience and five cases per week may not be that senior. In addition, the questionnaire was forwarded through WeChat groups, and it may have a low response rate. At the same time, participants’ reports of PTG may also be affected by social expectation bias. Additionally, this study only included psychiatrists and psychologists, and the attitudes and practices of other mental health professionals are worth exploring in the future.

5 Conclusion

Although the sample size is limited, this study reveals significant differences in attitudes toward PTG among Chinese psychiatrists and psychologists, likely influenced by their distinct professional roles and workplace environments. Our findings suggest that psychologists and practitioners in private institutions engage in PTG more frequently, while simultaneously harboring greater concerns about its use. This contradiction reflects their reliance on the therapeutic alliance and the high expectations of clients in private institutions.

These results highlight the unique challenges and potential risks associated with PTG practices in Chinese psychiatrists and psychologists. Future research should further explore the underlying factors contributing to these differences to better understand the role of PTG in different professional contexts. Moreover, the findings underscore the urgent need to develop ethical guidelines tailored to the Chinese context and to provide targeted training for both psychiatrists and psychologists to ensure that PTG practices are conducted safely and responsibly for both clients and professionals.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving humans were approved by The Ethics Committee of the Shanghai Mental Health Center (IORG0002202, FWA00003065). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

YF: Writing – original draft, Visualization, Validation, Software, Project administration, Investigation, Formal analysis, Data curation. XH: Writing – review & editing, Resources, Project administration, Methodology, Investigation, Data curation, Conceptualization. YQ: Writing – review & editing, Supervision, Resources, Project administration. YS: Writing – review & editing, Supervision, Resources, Project administration, Methodology, Funding acquisition.

Funding

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2024.1461514/full#supplementary-material

References

1. Clinton BK, Silverman BC, Brendel DH. Patient-targeted googling: the ethics of searching online for patient information. Harvard Rev Psychiatry. (2010) 18:103–12. doi: 10.3109/10673221003683861

Crossref Full Text | Google Scholar

2. Rowlands I, Nicholas D, Williams P, Huntington P, Fieldhouse M, Gunter B, et al. The google generation: the information behaviour of the researcher of the future. Aslib Proc. (2008) 60:290–310. doi: 10.1108/00012530810887953

Crossref Full Text | Google Scholar

3. Frampton JR, Fox J. Monitoring, creeping, or surveillance? A synthesis of online social information seeking concepts. Rev Communication Res. (2020) 9:1–42. doi: 10.12840/ISSN.2255-4165.025

Crossref Full Text | Google Scholar

4. Nuti SV, Wayda B, Ranasinghe I, Wang S, Dreyer RP, Chen SI, et al. The use of google trends in health care research: A systematic review. PloS One. (2014) 9:e109583. doi: 10.1371/journal.pone.0109583

PubMed Abstract | Crossref Full Text | Google Scholar

5. Arruda Filho EJM, Gammarano I, Duarte EMC. Smile, you're being watched: digital privacy and risk perception regarding data sharing on social networks. Interacting Computers. (2023) 35:12–23. doi: 10.1093/iwc/iwad027

Crossref Full Text | Google Scholar

6. Baker MJ, George DR, Kauffman GL. Navigating the google blind spot: an emerging need for professional guidelines to address patient-targeted googling. J Gen Internal Med. (2015) 30:6–7. doi: 10.1007/s11606-014-3030-7

Crossref Full Text | Google Scholar

7. Mousavi R, Chen R, Kim DJ, Chen K. Effectiveness of privacy assurance mechanisms in users' Privacy protection on social networking sites from the perspective of protection motivation theory. Decision Support Systems. (2020) 135:113323. doi: 10.1016/j.dss.2020.113323

Crossref Full Text | Google Scholar

8. Deen SR, Withers A, Hellerstein DJ. Mental health practitioners' Use and attitudes regarding the internet and social media. J Psychiatr practice. (2013) 19:454–63. doi: 10.1097/01.pra.0000438184.74359.88

Crossref Full Text | Google Scholar

9. Eichenberg C, Herzberg PY. Do therapists google their patients? A survey among psychotherapists. J Med Internet Res. (2016) 18:e3. doi: 10.2196/jmir.4306

PubMed Abstract | Crossref Full Text | Google Scholar

10. Cox KE, Simonds LM, Moulton-Perkins A. Patient-targeted googling by psychological therapists: A narrative review of the literature and ethical implications. Counselling Psychother Res. (2021) 23:288–99. doi: 10.1002/capr.12454

Crossref Full Text | Google Scholar

11. Kolmes K, Taube DOJPPR. Practice. Seeking Finding Our Clients Internet: Boundary Considerations Cyberspace. (2014) 45:3. doi: 10.1037/a0029958

Crossref Full Text | Google Scholar

12. Thabrew H, Sawyer A, Eischenberg C. Patient-targeted googling by New Zealand mental health professionals: A new field of ethical consideration in the internet age. Telemedicine e-Health. (2018) 24:818–24. doi: 10.1089/tmj.2017.0247

PubMed Abstract | Crossref Full Text | Google Scholar

13. Lehavot K, Barnett JE, Powers D. Psychotherapy, professional relationships, and ethical considerations in the myspace generation. Prof Psychology: Res Practice. (2010) 41:160–6. doi: 10.1037/a0018709

Crossref Full Text | Google Scholar

14. DiLillo D, Gale EB. To google or not to google: graduate students' Use of the internet to access personal information about clients. Educ Publishing Foundation. (2011) . p:160–6. doi: 10.1037/a0024441

Crossref Full Text | Google Scholar

15. Putnam EL. Patient-targeted googling: A mixed-methods examination of psychologists’ Perceptions and practices: old dominion university. Old Dominion University, located in Norfolk, Virginia, USA. (2022). doi: 10.25777/py18-qw36.

Crossref Full Text | Google Scholar

16. Wu KS, Sonne JL. Therapist boundary crossings in the digital age: psychologists’ Practice frequencies and perceptions of ethicality. Prof Psychology: Res Practice. (2021) 52:419. doi: 10.1037/pro0000406

Crossref Full Text | Google Scholar

17. Trub L, Magaldi D. Secret powers: Acts of Googling in the therapeutic relationship. J Clin Psychol (2021) 77:968–85. doi: 10.1002/jclp.23107

Crossref Full Text | Google Scholar

18. Koh S, Cattell GM, Cochran DM, Krasner A, Langheim FJP, Sasso DA. Psychiatrists’ Use of electronic communication and social media and a proposed framework for future guidelines. J Psychiatr Pract. (2013) 19(3):254–63. doi: 10.1097/01.pra.0000430511.90509.e2

PubMed Abstract | Crossref Full Text | Google Scholar

19. Tadmon D, Olfson M. Trends in outpatient psychotherapy provision by U.S. Psychiatrists: 1996–2016. Am J Psychiatry. (2021) 179:110–21. doi: 10.1176/appi.ajp.2021.21040338

PubMed Abstract | Crossref Full Text | Google Scholar

20. CNNIC. The 50th statistical report on China’s internet beijing (2022). Available online at: https://www.cnnic.com.cn/IDR/ReportDownloads/202212/P020221209344717199824.pdf. (Accessed September 4, 2023).

Google Scholar

21. Psychology J. General mental health insight annual report 2021-2022 (2022). Available online at: https://dti7xo5hqu.feishu.cn/file/BTUAbdvDYoQX6fxJiHHcO7Qmnug?from=from_copylink. (Accessed September 4, 2023).

Google Scholar

22. Zhou J, Liu L, Xue P, Yang X, Tang X. Mental health response to the covid-19 outbreak in China. Am J Psychiatry. (2020) 177:574–5. doi: 10.1176/appi.ajp.2020.20030304

PubMed Abstract | Crossref Full Text | Google Scholar

23. Rettinger L, Klupper C, Werner F, Putz P. Changing attitudes towards teletherapy in Austrian therapists during the covid-19 pandemic. J Telemedicine Telecare. (2021) 29(5):406–14. doi: 10.1177/1357633X20986038

Crossref Full Text | Google Scholar

24. Chen H, Phillips M, Cheng H, Chen Q, Chen X, Fralick D, et al. Mental health law of the people's republic of China (English translation with annotations): translated and annotated version of China's new mental health law. Shanghai Arch Psychiatry. (2012) 24:305–21. doi: 10.3969/j.issn.1002-0829.2012.06.001

PubMed Abstract | Crossref Full Text | Google Scholar

25. Huang H-Y. Untamed jianghu or emerging profession: diagnosing the psycho-boom amid China’s mental health legislation. Culture Medicine Psychiatry. (2018) 42:371–400. doi: 10.1007/s11013-017-9553-8

PubMed Abstract | Crossref Full Text | Google Scholar

26. Chester AN, Walthert SE, Gallagher SJ, Anderson LC, Stitely ML. Patient-targeted googling and social media: A cross-sectional study of senior medical students. BMC Med Ethics. (2017) 18:70. doi: 10.1186/s12910-017-0230-9

PubMed Abstract | Crossref Full Text | Google Scholar

27. Eichenberg C, Sawyer A. Do Patients Look up Their Therapists Online? An Exploratory Study among Patients in Psychotherapy. JMIR Ment Health. (2016) 3:e22. doi: 10.2196/mental.5169

PubMed Abstract | Crossref Full Text | Google Scholar

28. Asay PA, Lal A. Who’s googled whom? Trainees’ Internet and online social networking experiences, behaviors, and attitudes with clients and supervisors. Training Educ Prof Psychol. (2014) 8:105. doi: 10.1037/tep0000035

Crossref Full Text | Google Scholar

29. Ashby GA, O'Brien A, Bowman D, Hooper C, Stevens T, Lousada E. Should psychiatrists ‘Google’ Their patients? BJPsych Bulletin. (2015) 39:278–83. doi: 10.1192/pb.bp.114.047555

PubMed Abstract | Crossref Full Text | Google Scholar

30. de Araujo Reinert C, Kowacs C. Patient-targeted “Googling:” When therapists search for information about their patients online. Psychodynamic Psychiatry. (2019) 47:27–38. doi: 10.1521/pdps.2019.47.1.27

PubMed Abstract | Crossref Full Text | Google Scholar

31. APA. Revision of ethical standard 3.04 of the "Ethical principles of psychologists and code of conduct" (2002, as amended 2010). Am Psychol. (2016) 71:900. doi: 10.1037/amp0000102

PubMed Abstract | Crossref Full Text | Google Scholar

32. Gershengoren L. Patient-targeted googling and psychiatric professionals. Int J Psychiatry Med. (2019) 54:133–9. doi: 10.1177/0091217418791459

PubMed Abstract | Crossref Full Text | Google Scholar

33. Liu Z, Wang X, Liu J. How digital natives make their self-disclosure decisions: A cross-cultural comparison. Inf Technol People. (2019) 32:538–58. doi: 10.1108/ITP-10-2017-0339

Crossref Full Text | Google Scholar

34. Chen. Differences in self-disclosure patterns among americans versus chinese: A comparative study. J cross-cultural Psychol. (1995) 26:84–91. doi: 10.1177/002202219526100

Crossref Full Text | Google Scholar

35. Schug J, Yuki M, Maddux W. Relational Mobility Explains between-and within-Culture Differences in Self-Disclosure to Close Friends. psychol Science. (2010) 21:1471–8. doi: 10.1177/0956797610382786

Crossref Full Text | Google Scholar

36. Krasnova H, Veltri NF. (2010). Privacy calculus on social networking sites: explorative evidence from Germany and USA, in: 2010 43rd Hawaii International Conference on System Sciences, . doi: 10.1109/HICSS.2010.307

Crossref Full Text | Google Scholar

37. Trepte S, Masur PK. Cultural differences in social media use, privacy, and self-disclosure: research report on a multicultural study (2016). Available online at: http://opus.uni-hohenheim.de/volltexte/2016/1218/. (Accessed November 1, 2023).

Google Scholar

38. Xiang YT, Zhao YJ, Liu ZH, Li XH, Zhao N, Cheung T, et al. The covid-19 outbreak and psychiatric hospitals in China: managing challenges through mental health service reform. Int J Biol Sci. (2020) 16:1741–4. doi: 10.7150/ijbs.45072

PubMed Abstract | Crossref Full Text | Google Scholar

39. Xu H, Yuan M. Family roles in informed consent from the perspective of young chinese doctors: A questionnaire study. BMC Med Ethics. (2024) 25:2. doi: 10.1186/s12910-023-00999-6

PubMed Abstract | Crossref Full Text | Google Scholar

40. Howgego IM, Yellowlees P, Owen C, Meldrum L, Dark FJA. The therapeutic alliance: the key to effective patient outcome? A descriptive review of the evidence in community mental health case management. Psychiatry NZJo. (2003) 37:169–83. doi: 10.1046/j.1440-1614.2003.01131.x

Crossref Full Text | Google Scholar

41. Bachelor A. Clients' and therapists' Views of the therapeutic alliance: similarities, differences and relationship to therapy outcome. Clin Psychol Psychotherapy. (2013) 20:118–35. doi: 10.1002/cpp.792

Crossref Full Text | Google Scholar

42. Baier AL, Kline AC, Feeny NC. Therapeutic alliance as a mediator of change: A systematic review and evaluation of research. Clin Psychol Review. (2020) 82:101921. doi: 10.1016/j.cpr.2020.101921

Crossref Full Text | Google Scholar

43. Huggett C, Gooding P, Haddock G, Quigley J, Pratt D. The relationship between the therapeutic alliance in psychotherapy and suicidal experiences: A systematic review. Clin Psychol Psychotherapy. (2022) 29:1203–35. doi: 10.1002/cpp.2726

Crossref Full Text | Google Scholar

44. Banerjee I, Roy B, Banerjee I, Sathian B, Mondal M, Saha A. Depression and its cure: A drug utilization study from a tertiary care centre of western Nepal. Nepal J Epidemiol. (2011) 1:144–52. doi: 10.3126/nje.v1i5.6152

Crossref Full Text | Google Scholar

45. Greenway KT, Garel N, Jerome L, Feduccia AA. Integrating psychotherapy and psychopharmacology: psychedelic-assisted psychotherapy and other combined treatments. Expert Rev Clin Pharmacol. (2020) 13:655–70. doi: 10.1080/17512433.2020.1772054

PubMed Abstract | Crossref Full Text | Google Scholar

46. Kaluzeviciute G. The role of empathy in psychoanalytic psychotherapy: A historical exploration. Cogent Psychol. (2020) 7:1748792. doi: 10.1080/23311908.2020.1748792

Crossref Full Text | Google Scholar

47. Sayers J. Online psychotherapy: transference and countertransference issues. Br J Psychotherapy. (2021) 37:223–33. doi: 10.1111/bjp.12624

Crossref Full Text | Google Scholar

48. Huang H-Y. Therapy made easy: E-commerce and infrastructure in China’s psycho-boom. China Perspectives. (2017) 2017:29–39. doi: 10.4000/Chinaperspectives.7468

Crossref Full Text | Google Scholar

49. Gaines AN, Goldfried MR. Consensus in psychotherapy: are we there yet? Clin Psychology: Sci Practice. (2021) 28:267–76. doi: 10.1037/cps0000026

Crossref Full Text | Google Scholar

50. Trub L. Imagination foreclosed: searching for each other in the digital age. Psychoanalytic Perspectives. (2023) 20:146–69. doi: 10.1080/1551806X.2023.2188026

Crossref Full Text | Google Scholar

51. Li Fenglan GX. Investigation of the mental health service needs of the psychotic outpatients. Med Philosophy. (2017) 38(03):67–71. doi: 10.12014/i.issn.1002-0772.2017.03b.19

Crossref Full Text | Google Scholar

52. Jing Mengxin ZW, Qiao Ying ZY. Social psychological counseling services in China: A current situation analysis based on demand and services. psychol Commun. (2022) 5:58–65. doi: 10.12100/j.issn.2096-5494.222011

Crossref Full Text | Google Scholar

53. Elkins B. Community perceptions of patient targeted googling. University of Alaska Anchorage. (Ann Arbor, Michigan, USA: ProQuest LLC). (2020).

Google Scholar

54. Huang H-Y. Therapy made easy E-commerce and infrastructure in China's psycho-boom. China perspectives. (2017) 4:29–39. doi: 10.4000/Chinaperspectives.7468

Crossref Full Text | Google Scholar

55. Dike CC, Candilis P, Kocsis B, Sidhu N, Recupero P. Ethical considerations regarding internet searches for patient information. Psychiatr Serv (Washington DC). (2019) 70:324–8. doi: 10.1176/appi.ps.201800495

Crossref Full Text | Google Scholar

56. Perlstein R, McCoombe S, Shaw C, Nowson C. Medical students' Perceptions regarding the importance of nutritional knowledge and their confidence in providing competent nutrition practice. Public Health. (2016) 140:27–34. doi: 10.1016/j.puhe.2016.08.019

PubMed Abstract | Crossref Full Text | Google Scholar

57. Baraniuk S, Lodge R. Therapists' Experiences of “Internet exposure” in the therapeutic relationship: an interpretative phenomenological analysis. Couns Psychother Res. (2023) 23(3):808–17. doi: 10.1002/capr.12616

Crossref Full Text | Google Scholar

58. Dongmei W, Qian M-Y, Fan F-M, Jiang G-R. A brief history of the 100-year development of clinical and counseling psychology in China. Chin J Clin Psychol. (2022) 30(02):454–60. doi: 10.16128/j.cnki.1005-3611.2022.02.041

Crossref Full Text | Google Scholar

59. Cole A. Patient-targeted googling and psychiatry: A brief review and recommendations in practice. Am J Psychiatry Residents' J. (2017) 11(5):7–9. doi: 10.1176/appi.ajp-rj.2016.110504

Crossref Full Text | Google Scholar