Professional Psychology: Research and Practice

© 2018 American Psychological Association 2018, Vol. 49, No. 5-6, 336–344 0735-7028/18/$12.00 http://dx.doi.org/10.1037/pro0000219

Adolescents’ Perceptions of Their Therapists’ Social Media Competency and the Therapeutic Alliance

Jeanna Pagnotta, Fran C. Blumberg, Mary K. Alvord and Joseph G. Ponterotto Alvord, Baker & Associates, LLC, Rockville Fordham University and Chevy Chase, MD

Adolescents’ lives are now experienced in sophisticated digital environments, potentially warranting their consideration as a distinct cultural group. As such, clinicians who work with this population may be expected to be conversant with their clients’ digital habits to establish an efficacious therapeutic alliance and bolster treatment outcomes. We investigated linkages between adolescents’ social media habits and therapeutic alliance ratings based on perceptions of their therapists’ social media competency and traditional multicultural competency (MCC). Seventy-seven 14- to 17-year-olds currently receiving therapy services completed an online survey assessing their social media habits, perceptions of their therapists’ social media competency and traditional MCC, and ratings of therapeutic alliance. Adoles- cents’ perceptions of therapists’ social media competency positively predicted therapeutic alliance ratings, regardless of variations in participants’ social media use. A positive relationship was also found between perceived traditional MCC and therapeutic alliance ratings. Finally, preliminary validation for a newly adapted measure of therapists’ perceived social media competency was demonstrated. These findings may be among the first to establish social media competency as a contemporary form of MCC, which may inform new avenues for training and professional development for psychologists working with adolescents.

Public Significance Statement This study suggests that adolescents’ perceptions of their therapists’ social media competency may impact their perceptions of the therapeutic alliance. Additionally, the study introduces a new instrument for assessing perceptions of therapists’ social media competency.

Keywords: adolescent psychotherapy, therapeutic alliance, multicultural competency, social media

National surveys attest to adolescents’ heavy reliance on Media, 2012). Given their increasing ownership of smartphones social media as a vehicle for communication and self- and mobile devices, 92% of teens report going online daily, expression. “Social media” is operationalized as media used to including 24% who report doing so “almost constantly” (Len- communicate with more than one person at a time via social hart, 2015). According to a recent survey by Pew Research networking sites such as Facebook, microblogging sites such as Center, 90% of all American teens have used social media, and Twitter and Tumblr, blogs, and multiplayer online games or 75% of these teens have social networking profiles. Nearly one virtual worlds that include text or voice chat (Common Sense in three teens visit their social networking profile several times This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

JEANNA PAGNOTTA received her PhD in counseling psychology from counseling psychology at Fordham University and a psychologist in Fordham University. She completed her predoctoral internship at Kings private practice working with adolescents and adults. His professional County Hospital and is pursuing her postdoctoral training at the Williams- interests are multicultural counseling, career development, and psycho- burg Therapy Group in Brooklyn, New York. Her research interests in- biography. clude media psychology, adolescent identity development, and multicul- MARY K. ALVORD received her PhD in school psychology with a clinical tural counseling. This article is based on her doctoral dissertation. emphasis from the University of Maryland. She is currently the director of FRAN C. BLUMBERG received her PhD in developmental psychology Alvord, Baker & Associates, LLC, an independent therapy practice in from Purdue University. She is a professor in the Division of Psychological Rockville and Chevy Chase, MD. Her areas of professional interest include and Educational Services within Fordham University’s Graduate School of resilience, social competence, anxiety, public education and media psy- Education. Her research interests concern children’s and adolescent’s chology. learning and problem-solving in the context of digital media-based settings. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to JOSEPH G. PONTEROTTO received his PhD in counseling psychology Jeanna Pagnotta, 64 Bayard street, #PHC, Brooklyn, NY 11222. E-mail: from the University of California at Santa Barbara. He is a professor of [email protected]

336 SOCIAL MEDIA COMPETENCY AND THE THERAPEUTIC ALLIANCE 337

a day or more, with 71% of teens using more than one social For example, Lewis and Wahesh (2012) utilized Facebook to help networking site (Lenhart, 2015). adolescent clients identify and modify maladaptive thought pat- Clearly, youth are navigating their adolescence in more sophis- terns. Their results indicated that adolescents’ insight into their ticated digital environments than previous generations which has self-presentation on Facebook might promote self-awareness and ramifications for culturally normative practices that promote dis- consequently facilitate prosocial responding in relationships. tinct developmental trajectories (Packer & Cole, 2015). Cultural The awareness component of MCC refers to therapists’ consid- practices are exemplified via peer relationships, through which erations of their clients’ cultural identities, and recognition of how adolescents develop and reinforce shared norms, engage in inti- their own identities bias their work with clients (Sue & Sue, 2003). mate self-disclosure, and learn to articulate their personal narra- Thus, therapists should be aware of the cultural salience of social tives (Davis, 2012; Sullivan, 1953). Before the advent of media in their adolescent clients’ lives, and acknowledge that their sophisticated communication technology, these practices largely online experiences are likely to differ from those of their clients. occurred in the context of in-person interactions. However, re- For example, 20% of social media-using teens reported that people search findings within the current digital age suggests that self- were mostly unkind to one another on social networking sites, presentation and self-disclosure among adolescents increasingly while only 5% of social media-using adults reported the same occurs via the Internet, which allows for near constant contact with (Lenhart et al., 2011). Overall, therapists may increase their MCC peers (Fullwood, James, & Chen-Wilson, 2016; Valkenburg & by learning about social media and encouraging open dialogue Peter, 2011). considering ways in which social media impacts the values, life- In fact, this cohort may arguably constitute a distinct cultural style choices, and concerns of their adolescent clients. group. This appellation is appropriate as culture has been broadly Findings show that therapist MCC is positively associated with conceptualized as the medium in which biological, cognitive, counseling satisfaction and treatment outcomes. Griner and social, and emotional aspects of development are co-constituted Smith’s (2006) meta-analysis examining the efficacy of culturally (Packer & Cole, 2015). Digital media provides this medium for adapted interventions revealed that interventions that were tailored today’s adolescents, enabling them to co-construct the online con- to the needs of specific racial and ethnic groups were four times texts in which important developmental issues such as sexuality, more effective than generalized interventions. Research also sug- identity, and peer relations are enacted. The American Psycholog- gests that higher ratings on therapist MCC are positively associ- ical Association’s (APA; 2002) Guidelines on Multicultural Edu- ated with important therapeutic processes, including the therapeu- cation, Training, Research, Practice and Organizational Change for tic alliance (Tao, Owen, Pace, & Imel, 2015). As conceptualized Psychologists encourage psychologists to employ a culture- by Bordin (1979), the therapeutic alliance refers to a collaborative centered approach to treatment by conceptualizing their clients’ attachment between client and therapist, consisting of three inter- psychological functioning via the sociocultural contexts in which related components: bond, tasks, and goals. Identified as one of the they engage. The same considerations should be made for new most important factors in therapeutic effectiveness, the therapeutic generations of adolescents whose media-related cultural practices alliance may be crucial for client motivation to attend sessions and produce unique developmental and psychological outcomes. engage in the work of therapy. In fact, findings from meta-analyses (McLeod, 2011; Shirk, Karver, & Brown, 2011) have shown that Multicultural Competency and the Therapeutic the efficacy of adolescent therapy is closely linked to therapists’ Alliance ability to design culturally relevant interventions and form mean- ingful relationships with their clients. The most widely accepted conceptualization of multicultural competency (MCC) is based in the tripartite model of Sue, Arre- dondo, and McDavis (1992) and Sue et al. (1998), whereby psy- Engaging Adolescents in Treatment Via Social Media chotherapists’ competent care entails acquiring knowledge, skills, Competency and awareness of their own and their clients’ culture. The knowl- edge component pertains to clinicians expanding their understand- Examining factors that influence adolescent engagement in ther- ing of clients’ cultural background and worldview (Sue & Sue, apy may promote mental health treatment among this vulnerable 2003). Thus, when counseling digitally immersed youth, therapists population. Findings show that an estimated 22% of U.S. adoles- This document is copyrighted by the American Psychological Association or one of its allied publishers. should remain informed about the cultural norms related to social cents ages 13–18 have been diagnosed with a severe mental health This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. media use to accurately assess normative (i.e., prosocial commu- condition, half of which begin by age 14 (Merikangas et al., 2010). nication with peers) versus problematic (i.e., cyberbullying or Left untreated, adolescent mental illness is associated with sub- Internet addiction) behavior. For example, several studies have stance abuse, academic underachievement, poor social relation- demonstrated that up to 90% of adolescents fail to report instances ships, unemployment, legal problems, and suicide, which is cur- of cyberbullying to adults, largely because they believe that adults rently the third leading cause of death among youth (Munson, will not understand or respond in an appropriate manner (Gao, Floersch, & Townsend, 2009). Though many psychological disor- Zhao, & McJunkin, 2016). ders are treatable with early intervention, an estimated 50%–75% The skills component of MCC refers to therapists’ ability to of adolescents referred to treatment do not initiate or complete its communicate with clients in culturally appropriate styles and im- full course, and the average delay between onset of symptoms and plement culturally appropriate interventions (Sue & Sue, 2003). intervention is 8–10 years (Merikangas et al., 2010; Thompson, Thus, therapists should become well-versed in the various social Bender, Lantry, & Flynn, 2007). Reasons for this underuse include media platforms utilized by their adolescent clients to foster in- lack of access to care, negative stigma about mental illness, and creased connection and facilitate media-competent treatment tasks. personal ambivalence about the efficacy of therapy itself. 338 PAGNOTTA, BLUMBERG, PONTEROTTO, AND ALVORD

To date, numerous studies have implicated adolescents’ media Sue et al.’s (1992, 1998). tripartite model of multicultural compe- use as a risk factor for psychological distress (Ehrenreich & tence, social media competency was operationalized as the extent Underwood, 2016; Sampasa-Kanyinga & Lewis, 2015). However, to which therapists displayed knowledge, skill, and awareness factors other than social media itself are largely responsible for the regarding their clients’ digital lives. harmful consequences associated with its use among adolescents. We hypothesized that: (a) therapists’ perceived social media com- For example, Davila et al. (2012) found that depressive symptoms petency would positively predict therapeutic alliance ratings among were correlated with rumination about negative online experi- social media-using adolescents; (b) social media use would moderate ences, rather than online use alone. Similarly, Valkenburg and the relationship between therapists’ perceived social media compe- Peter (2011) found that communication with strangers online ac- tency and therapeutic alliance ratings, whereby perceived social me- counted for the negative relationship between Internet communi- dia competency would be a stronger predictor of therapeutic alliance cation and adolescent well-being. These findings suggest that ratings for adolescents with higher rates of social media use; and (c) therapists should consider how youth are functioning within the therapists’ perceived traditional MCC would positively predict ther- cultural context of social media, including the nuances of their use, apeutic alliance ratings among social media-using adolescents. rather than addressing the deleterious effects of technology overall. Another key motivator for therapists’ competency regarding ado- Method lescent social media use is the range of social media-based issues for which adolescents may now present for therapy, such as cyberbully- ing, which refers to electronic media use to bully or harass an Participants individual (Underwood & Ehrenreich, 2017). In fact, cybervictimiza- Participants included 77 adolescents (62.3% female), aged tion has been linked to multiple negative outcomes, including low 14- to 17-years-old (M ϭ 15.51 years; SD ϭ 1.10). Table 1 self-esteem, symptoms of anxiety and depression, and suicidal ide- shows detailed participant demographics. All participants re- ation (Landoll, La Greca, Lai, Chan, & Herge, 2015). Many teens also ported using at least one form of social media. All participants engage in social media practices that may compromise their safety had been attending individual talk therapy at least bimonthly, and jeopardize future employment, such as lying about their age, for a minimum of five sessions. This criterion was selected revealing personal information, or posting sexually inappropriate pic- given findings that the quality of the therapeutic relationship is tures (Lenhart et al., 2011). The increasing prevalence of these social established within the first five sessions and remains relatively media-related issues underscores therapists’ need to become social stable over the course of treatment (Bordin, 1979; Horvath & media-competent, which entails developing interventions that address Greenberg, 1989; Horvath & Marx, 1991). Table 2 shows the issues adolescents face in cyberspace. detailed therapy-related demographics. Therapists are now incorporating media use into their clinical work in diverse ways, such as Qureshi, Claudio, and Mendez’s (2015) use of Facebook as an intervention tool for the treatment of substance abuse in urban adolescents. Social media is also used to Table 1 increase compliance with health-related recommendations be- Demographic Characteristics of Study Participants tween visits and to disseminate important information about ado- lescent health topics, including sexual health, drug and alcohol use, Category n % safety, school performance, and mental health (Wong, Merchant, Grade level & Moreno, 2014). Preliminary results show these social media- 8 6 7.8 based interventions are highly efficacious for fostering self- 9 14 18.2 awareness, accessing underserved adolescents, and reducing the 10 26 33.8 shame and stigma associated with mental illness (Wong et al., 11 21 27.3 12 10 12.9 2014). Overall, social media-competent treatment can facilitate Sex more personalized, culturally salient interventions for digitally Male 29 37.7 immersed adolescents, potentially bolstering the therapeutic alli- Female 48 62.3 ance and enhancing treatment outcomes. Race/ethnicity This document is copyrighted by the American Psychological Association or one of its allied publishers. White/Caucasian 64 83.1

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Black/African American 3 3.9 The Present Study Hispanic/Latino/Latina 4 5.2 Biracial/Multiracial 6 7.8 This study may be among the first to investigate perceived Diagnosis social media competency as a determinant of therapeutic success. Major depressive disorder 18 23.4 Persistent depressive disorder 8 10.4 One related concern was whether perceived multicultural compe- Generalized anxiety disorder 49 63.6 tency (MCC), as traditionally conceptualized, would positively Social phobia 23 29.9 predict therapeutic alliance ratings among social media-using ad- Other anxiety disorder 6 7.8 olescents. MCC has been shown to predict therapeutic alliance Annual household income Less than $20,000 7 9.1 among adult populations, but little is known about its importance $20,000–$39,999 12 15.6 among adolescent populations (Swan, Schottelkorb, & Lancaster, $40,000–$59,999 17 22.1 2015). Another related concern was the validity of assessing ther- $60,000–$79,999 20 26.0 apists’ perceived social media competency using a new measure, $80,000–$99,990 11 14.3 the Social Media Counseling Inventory (SMCI). Consistent with More than $100,000 10 13.0 SOCIAL MEDIA COMPETENCY AND THE THERAPEUTIC ALLIANCE 339

Table 2 disagree)to6(strongly agree). An additional answer choice of Therapy-Related Demographics of Study Participants “N/A” (not applicable) was included in the CCCI-R, to account for certain scale items that may have been irrelevant for some partic- Category Range MSDipants. # Sessions attended 5–120 21.64 21.23 The CCCI-R is composed of three subscales assessing: (a) # Months in treatment 2–60 11.03 12.12 cross-cultural counseling skills, (b) sociopolitical awareness, and Therapist age (approx.) 27–65 40.77 8.27 (c) cultural sensitivity. Scores on the CCCI-R range from 20 to Category n%120, with higher scores indicating higher perceived cultural com- petence. To account for “N/A” responses, a weighted average # Sessions per month score was calculated for each participant by dividing their total 2 51 66.2 3 7 9.1 score by the number of valid (non-N/A) responses. Participants’ 4 18 23.4 weighted average scores on the CCCI-R were included in the final 5 1 1.3 analysis. Type of therapist (degree) The CCCI-R is one of the most widely used client-rated mea- Ph.D. or Psy.D. 25 32.5 sures of therapists’ perceived multicultural competence. The M.A. or M.S. 19 24.7 M.S.W. or L.C.S.W. 17 22.1 CCCI-R has adequate internal consistency and reliability, with a M.D. 10 13.0 coefficient alpha of .95 and reliability coefficients ranging from Not sure 6 7.8 .78 to .84 (Ponterotto, Rieger, Barrett, & Sparks, 1994). The Therapist gender criterion and content validity of the CCCI-R have also been found Male 18 23.4 Female 59 76.6 to be adequate. The CCCI-R administered here was similarly consistent (␣ϭ.89). Perceived social media competency. Therapists’ perceived Measures social media competency was assessed using a newly adapted version of the CCCI-R—the Social Media Counseling Inventory Demographics/screening questionnaire. Parents completed (SMCI)—which asked specifically about perceived cultural com- a demographics/screening questionnaire eliciting information petency concerning social media use. These 14 items were gener- about participants and their eligibility for participation. Parents ated through slight adjustments to the original CCCI-R items (i.e., were asked to report their child’s age, gender, race/ethnicity, level replacing the word “culture” with “social media”). Six items from of education, psychiatric diagnosis, length and frequency of treat- the CCCI-R were removed because they did not lend themselves to ment, and therapist demographics (i.e., age, gender, degree), and to inquiry about social media use in a therapeutic context. The report their yearly household income. deleted items were proportionately distributed among the three Social media use survey. All participants completed a survey subscales to preserve the item ratios of the original instrument. assessing their social media habits. This survey was adapted from Scores on the SMCI ranged from 14 to 84, with higher scores one used in 2012 by Knowledge Networks: A Gfk Company indicating higher perceived social media competency. To account (Common Sense Media, 2012), and from a more recent survey for “N/A” responses, a weighted average score was calculated for conducted by Pew Research Center (Lenhart, 2015). The adapted each participant by dividing their total score by the number of questionnaire included questions regarding participants’ media valid responses. Participants’ weighted average scores on the device ownership, social media accounts, and frequency of use. SMCI were included in the final analysis. Questions also assessed participants’ use of specific social media Before data collection, a review panel of Ph.D. psychologists sites, including Facebook, Instagram, and Snapchat, which are the with expertise in developmental psychology, multicultural coun- most popular social media platforms used among teens (Lenhart, seling, and media psychology qualitatively evaluated the SMCI to 2015). establish the content validity of the adapted items. Additionally, All questions (25 items) pertaining to participants’ media device adolescent pilot tests consisting of SMCI administration and ownership, social media account membership, and frequency of follow-up interviews with six adolescents were conducted to as- social media use were scored and used to generate a social media sess the clarity and relevance of the items. Using Microsoft Word, This document is copyrighted by the American Psychological Association or one of its allied publishers. use score for each participant. Items pertaining to media device the Flesch-Kincaid reading level was estimated at eighth grade, This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. ownership (five items) and social media account membership (nine which was deemed appropriate for the target sample. Following items) were awarded 1 point. Items pertaining to frequency of data collection with the final study sample, psychometric analyses social media use (11 items) were rated on a 7-point Likert scale revealed high internal consistency of the SMCI, with a Cronbach’s ranging from 0 (never)to6(almost constantly). Scores ranged alpha of .87. Detailed psychometric data are presented in the from 0 to 80, with higher scores indicating higher social media use. results. Participants’ total score was included in the analysis. Ratings of therapeutic alliance. Adolescents’ ratings of their Perceived multicultural competence. Therapists’ perceived perceived alliance with their therapist were measured using the MCC, as traditionally conceptualized, was assessed using the Working Alliance Inventory—Short Form Revised (WAI-SR; Cross-Cultural Counseling Inventory–Revised (CCCI-R; LaFrom- Hatcher & Gillapsy, 2006). This scale includes 12 items rated on boise, Coleman, & Hernandez, 1991). This scale was developed a 5-point Likert scale ranging from 1 (never)to5(always), with based on the tripartite model of MCC (i.e., knowledge, skills, and higher scores indicating a better therapeutic alliance. Consistent awareness; Sue et al., 1992, 1998). The CCCI-R contains 20 items, with Bordin’s (1979) conceptualization of therapeutic alliance, the each rated on a 6-point Likert-type scale ranging from 1 (strongly WAI-SR measures the quality of the therapeutic relationship 340 PAGNOTTA, BLUMBERG, PONTEROTTO, AND ALVORD

across three subscales: bond, tasks, and goals. Possible scores survey: (a) an attention filter (i.e., “This is an attention filter. range from 12 to 60, with a higher score indicating a stronger Please select strongly disagree”); and (b) a speeding check (i.e., therapeutic alliance. Participants’ total score was included in sub- participants were excluded if they finished in under 5 min). sequent analyses. Of the 551 parents who started the demographics/screening The WAI and its various forms have been shown as reliable and questionnaire, 85 adolescents were deemed eligible and completed valid for measuring working alliance among youth populations, the entire survey. The ineligible participants were excluded based with reliability estimates ranging from .79 to .97 (Hanson, Curry, on the inclusion/exclusion criteria as follows: age (126), diagnosis & Bandalos, 2002). High internal consistency has also been dem- (83), attending therapy (68), self-harm (63), hospitalization (54), onstrated, with Cronbach’s alpha scores ranging from .85 to .98 bimonthly sessions (32), attended five sessions (14), assent to (Hanson et al., 2002; Horvath & Greenberg, 1989). The WAI-SR participate (3), and English fluency (two). An additional 21 par- administered here was similarly consistent (␣ϭ.94). ticipants were excluded for failing the attention filter (17), speed- ing check (one), or not starting the survey (three). Eight partici- Procedure pants were removed from the data analysis for ostensibly aberrant response patterns, such as straight-lining (i.e., selecting strongly After obtaining institutional review board approval from Ford- agree or strongly disagree for all questions, across all scales). A ham University, participants were recruited via Qualtrics, a web- final sample of 77 adolescent participants was congruent with an a based survey platform that samples from a large network of priori power analysis, which estimated a significance level of .05, actively managed research panels. Invitations for participation power of .80, and moderate effect size. were e-mailed to parents of potentially eligible adolescents. A parental consent letter and adolescent assent letter were included, detailing the study purpose, requirements for participation, right to Results withdraw without penalty, risks and benefits of participation, con- Table 3 presents descriptive statistics for scores on the Social fidentiality, and information about the principal investigator. In- Media Use Survey, CCCI-R, SMCI, and WAI-SR, including Pear- centives for participation consisted of $10 cash or gift card. son correlation coefficients among the study variables. Parents’ responses to the demographics/screening survey were used to identify eligible participants, who were required to be Principle Component Analysis of the SMCI fluent and literate in English, and currently attending therapy for at least one of the following diagnoses: major depressive disorder, Given that the SMCI was newly developed for this study, we persistent depressive disorder, generalized anxiety disorder, or conducted a principal component analysis (PCA) to examine the social phobia. These diagnoses were selected as depression and underlying factor structure of the 14-item instrument. The com- anxiety are among the most prevalent adolescent disorders, and munalities among SMCI items ranged from .40 to .80, supporting have been linked to social media use (Ehrenreich & Underwood, the inclusion of all 14 items in the factor analysis. Initial eigen- 2016; Merikangas et al., 2010). Participants were excluded if they values (Ͼ1.0) indicated that three components were found to had been diagnosed with bipolar disorder, psychosis, autism spec- explain 59.28% of the variance (40.35%, 10.20%, and 8.83%, trum disorder, personality disorder, or intellectual handicap, or respectively). Orthogonal (varimax) rotation was conducted using if they had been hospitalized for a psychiatric reason or expressed this three-factor model to determine the factor loadings of each thoughts of suicide within the past month, as these conditions SMCI item. Table 4 shows the resultant factor loading matrix. typically require a higher level of care than psychotherapy alone. Our observed structure deviated substantially from the three- Parents of eligible participants were instructed to pass the sur- factor structure of the original CCCI-R, indicating that the SMCI vey to their child at the completion of the demographics/screening may be comprised of three unique subscales. Figure 1 shows a questions. After providing assent, adolescent participants were comparison of the expected versus observed SMCI structure. The prompted to complete a 15-min survey containing the Social three new subscales were named for the item content that loaded Media Use Survey, the CCCI-R, the SMCI, and the WAI-SR (in most strongly onto them. The first was named “awareness and the same order, with instructions presented before each). To opti- respect,” as the items considered the extent to which therapists mize response validity, two controls were embedded within the acknowledged their clients’ status as social media users and dem- This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Table 3 Descriptive Statistics, Reliability Coefficients, and Pearson Correlation Coefficients of Scale Scores

Correlations Scale Range MSD␣ Social media use CCCI-R SMCI WAI-SR

Social media use 9–52 31.60 10.56 — — CCCI-R 3.73–6.00 5.12 .51 .89 .02 — — ءSMCI 3.57–6.00 4.85 .56 .87 Ϫ.12 .72 — ء74. ءWAI-SR 19–60 48.22 9.03 .94 Ϫ.10 .56 Note. N ϭ 78. CCCI-R ϭ Cross Cultural Counseling Inventory-Revised; SMCI ϭ Social Media Counseling Inventory; WAI-SR ϭ Working Alliance Inventory-Short Revised. .p Ͻ .01 ء SOCIAL MEDIA COMPETENCY AND THE THERAPEUTIC ALLIANCE 341

Table 4 subscales and the existence of three independent factors. The Rotated Component Matrix (Factor Loadings of SMCI Items) overall scale demonstrated high internal consistency (␣ϭ.87), while the individual subscales’ coefficient alphas varied as fol- Item Component 1 Component 2 Component 3 lows: subscale 1 (␣ϭ.85), subscale 2 (␣ϭ.81), subscale 3 (␣ϭ Given the low coefficient alpha on the third subscale, the total .(05. ء69. 1 score was included in subsequent analyses, and is advised in 36. ء66. 2 ء 3 .60 .46 advance of further scale validation. ء73. 4 ء55. 48. 5 Examination of Hypotheses ء82. 6 ء84. 7 A hierarchical regression analysis was conducted to determine ء 8 .68 ’the extent to which adolescents’ social media use, therapists 49. ء57. 9 perceived traditional MCC, and therapists’ perceived social media ء82. 10 competency predicted therapeutic alliance ratings, and to explore a 37. ء57. 11 ء 12 .39 .41 possible interaction between perceived social media competency ء75. 13 .and social media use 45. ء63. 14 The criterion variable was therapeutic alliance ratings (WAI-SR Note. Only factor loadings Ͼ .30 are reported. The full wording of each score). The overall regression model was statistically significant item is presented in Figure 1. 2 ϭ Ͻ Indicates the highest factor loading for that item. (R .552, p .001). Step 1 included adolescent social media use ء (Social Media Use Survey score), which did not predict therapeutic alliance ratings. Step 2 comprised therapists’ perceived traditional onstrated respectful awareness surrounding their values as such. MCC (CCCI-R score), which added 31.5% variance in predicting The second subscale was named “knowledge and skills,” as the therapeutic alliance ratings (p Ͻ .001). Step 3 consisted of per- items considered the extent to which therapists demonstrated prac- ceived social media competency (SMCI score) which added an tical knowledge about pertinent social media-related issues, and additional 22.7% variance in predicting therapeutic alliance ratings translated this knowledge into appropriate interventions. The third (p Ͻ .001). Step 4 examined the interaction between perceived subscale was named “navigating differences,” as the items consid- social media competency and social media use, which was not ered how therapists managed differences between their own social significant. Thus, therapists’ perceived social media competency media use and that of their adolescent clients. was the strongest predictor of therapeutic alliance ratings, above The correlations between subscale scores were low to moderate and beyond traditional MCC. Further, adolescent social media use (.18, .28, and .57), supporting the lack of redundancy among did not moderate this relationship.

SMCI Items Grouped by Original CCCI-R Subscales SMCI Items Grouped by New Subscales Cross-Cultural Counseling Skills Awareness and Respect 1. My therapist is aware of my social media use. 1. My therapist is aware of my social media use. 2. My therapist values and respects my social media use. 2. My therapist values and respects my social media use. 4. My therapist is comfortable with different social media 3. My therapist is aware of his/her own values regarding habits that I may have. social media and how they might affect me. 7. My therapist is able to suggest intervention skills that 4. My therapist is comfortable with different social media favor my social media use. habits that I may have. 8. My therapist sends messages that are appropriate in 11. My therapist is at ease talking to me about social media. communicating with me about my social media use. 13. My therapist appreciates my status as a social media 11. My therapist is at ease talking to me about social media. user. 14. My therapist acknowledges any differences between our 14. My therapist acknowledges any differences between our social media habits and is comfortable with them. social media habits and is comfortable with them. Sociopolitical Awareness Knowledge and Skills 3. My therapist is aware of his/her own values regarding 5. My therapist demonstrates knowledge about the social This document is copyrighted by the American Psychological Association or one of its allied publishers. social media and how they might affect me. media platforms that I use.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 6. My therapist is aware of social media related issues which 6. My therapist is aware of social media related issues which might affect my life. might affect my life. 9. My therapist attempts to understand my problems within 7. My therapist is able to suggest intervention skills that the context of my social media habits. favor my social media use. 13. My therapist appreciates my status as a social media 8. My therapist sends messages that are appropriate in user. communicating with me about my social media use. Cross-Cultural Sensitivity 9. My therapist attempts to understand my problems within 5. My therapist demonstrates knowledge about the social the context of my social media habits. media platforms that I use. Navigating Differences 10. My therapist presents his/her own values regarding 10. My therapist presents his/her own values regarding social media toward me. social media toward me. 12. My therapist recognizes limits determined by the 12. My therapist recognizes limits determined by the differences that exist between us surrounding social differences that exist between us surrounding social media use. media use.

Figure 1. Expected versus observed factor structure of the SMCI. 342 PAGNOTTA, BLUMBERG, PONTEROTTO, AND ALVORD

Discussion ence between adolescents and their therapists. Additionally, be- cause the CCCI-R has been predominantly used with adult popu- The findings supported the notion that therapists’ perceived lations, future studies should continue to explore and adapt this social media competency impacts perceptions of important thera- measure as a valid scale for younger populations. peutic processes such as the therapeutic alliance. Contrary to the While the racial homogeneity of the sample limits the general- original hypothesis whereby perceived social media competency izability of the findings to other racial and ethnic groups, it is was expected to be a stronger predictor of therapeutic alliance worth noting that the racial breakdown of this study reflects among adolescents with higher rates of social media use, we found general mental health trends in the United States. Minority ado- that social media competency was equally important among all lescents utilize mental health services significantly less than White social media-using adolescents. Thus, social media may be so adolescents and demonstrate higher therapy dropout rates (de ingrained in current adolescents’ sociocultural identities that any Haan, Boon, de Jong, Geluk, & Vermeiren, 2014). Nonetheless, amount of use is sufficient to expect that others in their environ- future research should examine the extent to which social media ment, such as their therapist, also would be social media savvy. competency predicts therapeutic alliance ratings among adoles- Given the positive relationship demonstrated between therapists’ cents of diverse racial and ethnic groups. perceived social media competency and therapeutic alliance rat- Further efforts should address formal validation of the newly ings, employing a media-competent approach to treatment may adapted SMCI, which revealed promising results in the prelimi- help to engage adolescents in therapy and improve their therapeu- nary PCA. Although several measures were taken to establish its tic outcomes. validity throughout the development process, further administra- Preliminary analyses of the newly adapted SMCI suggest that tions of the new measure to large samples are necessary to confirm the observed link between social media competency and therapeu- the observed factor structure and validate the measure for future tic alliance may be driven by the extent to which therapists display use in practice and research. Particularly needed will be structural awareness and respect surrounding adolescents’ social media use. equation modeling and confirmatory factor analysis with large Further, therapists may need to develop specific knowledge re- national samples. Such studies could also test the factor invariance garding the social media platforms that adolescent clients fre- across sample cohorts such as gender, income level, geographic quently use and the potential issues associated with them. For region, race, and ethnicity, among other individual difference example, Utz, Muscanell, and Khalid (2015) found that Snapchat factors. Once the SMCI is further validated it could be used in elicited higher levels of jealousy than Facebook among college research to more directly assess the construct’s relationship to students. Given these findings, therapists may consider incorpo- therapeutic processes and outcomes among social media-using rating a social media use questionnaire (such as the Social Media adolescents as well as emerging and young adults. Use Survey used here) into therapeutic intake procedures with new As an exploratory study, there are a number of limitations. First, adolescent clients. This type of survey could ascertain useful the study relied exclusively on self-report data based on the per- information about new clients’ social media habits, including the ceptions of the participants and their parents. As such, certain data specific social media platforms they use, their social media pref- might not be fully accurate, such as the psychiatric diagnoses erences (i.e., Snapchat vs. Facebook), and the frequency with indicated by parents. Second, no data was obtained about the which they use these platforms. Questions also may be included to extent to which therapists actually use social media or apply it to elicit social media-related issues that new clients may be grappling treatment, so the findings are based on perceptions of, rather than with, such as cybervictimization or online abuse. At minimum, the therapists’ actual competencies. Third, possible confounding administering this type of survey would provide therapists with variables were not adequately examined, including variations in useful information to help guide treatment and identify the areas in length of treatment and therapist demographics. Future studies which to expand their social media competency. At best, this may seek to include a survey of therapists, as well as a more practice could provide an opening to engage adolescents in a comprehensive analysis of covariates. Finally, data collection re- dialogue about their digital lives and convey a sense of awareness lied exclusively on survey instruments, raising issues about shared that facilitates the therapeutic alliance. method variance and directionality of the results. Future research Our findings also established therapists’ traditional MCC as a on this topic should expand this methodology to include experi- positive predictor of therapeutic alliance ratings among social mental analogue designs, and in-depth qualitative research inclu- This document is copyrighted by the American Psychological Association or one of its allied publishers. media-using adolescents, further supporting the need for therapists sive of interviews with clients, therapists, and family members. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. to become competent surrounding all aspects of their clients’ Future studies should also recruit participants from clinical set- cultural identities. However, the correlation between therapist tings, such as counseling centers and hospitals, to extend the MCC and therapeutic alliance observed in the present study (r ϭ generalizability of the results beyond the scope of Qualtrics survey .56) was smaller than those previously demonstrated among adult panels. populations, which have been as large as r ϭ .73 (Tao et al., 2015). Despite these limitations, the findings have practical implica- This discrepancy may be partially attributed to the predominantly tions for how cultural competency and cultural identity are con- (83%) White sample, as White adolescents may not experience as ceptualized from a therapeutic standpoint. While traditional MCC many culturally salient issues as adolescents of color. However, should be practiced with respect to all aspects of clients’ cultural this issue warrants further exploration, as cultural identity extends identities, social media competency appears to be a highly salient far beyond race (e.g., gender, religion, sexual orientation). therapeutic determinant among all adolescents, regardless of other Follow-up studies should include consideration of therapists’ cul- diversity factors. As such, clinicians working with adolescent tural identities and demographic characteristics, as the present clients may consider employing a media-competent approach to all results may also be explained by a high level of cultural congru- aspects of treatment. SOCIAL MEDIA COMPETENCY AND THE THERAPEUTIC ALLIANCE 343

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