Kaylen’s scenario illustrates the new and unique situations therapists and clients are encountering in the age of digital media. Psychologists are no longer practicing behind closed doors. Although they have appeared in mass media for decades, the rise of streaming platforms, podcasts, and social media has expanded the scale, immediacy, and reach of their public presence. Psychologists are appearing on mainstream television shows, hosting popular weekly podcasts, and building social media followings comparable to those of many mainstream celebrities. These practices raise questions that the American Psychological Association’s (APA) Ethical Principles of Psychologists and Code of Conduct (hereafter referred to as the Ethics Code; APA, 2017) does not explicitly address. These questions include the following: How do the foundational principles of confidentiality, informed consent, and competence apply when the therapeutic encounter becomes publicly available content? Where is the line between psychoeducation and clinical practice? And who is responsible for the harms that can result from the blurring of these lines? 

This article reviews three illustrative case examples from popular therapy-in-media contexts: the Showtime docuseries Couples Therapy, Esther Perel’s podcast Where Should We Begin?, and the social media presence of clinical psychologist Dr. Julie Smith. The most contextually relevant Ethics Codes will be reviewed for each case, along with reflection on the adequacy of our current professional guidelines, including the Ethics Code (APA, 2017) and the APA Guidelines for the Optimal Use of Social Media in Professional Psychological Practice (2021). The practitioners and scenarios were chosen not due to any wrongdoing on their part, but rather for the innovative ways they have brought psychotherapy into the public eye, and the popularity of their platforms. By examining the evolving integration of psychotherapy into popular culture, and the ethical tensions that arise, we aim to support clinicians in engaging in media thoughtfully in ways that maximize benefit and minimize harm. 

Case 1: Television - Couples Therapy

One of the most widely discussed experiments in bringing therapy to the public screen is the docuseries Couples Therapy, currently in its 5th season on Paramount+ with Showtime. The docuseries follows Dr. Orna Guralnik, a clinical psychologist and psychoanalyst practicing in New York City, as she works with real couples over the course of 6 months of weekly sessions (Guralnik, n.d.). Additionally, the series documents Dr. Guralnik’s clinical consultation meetings with her colleague, Dr. Virginia Goldner, also a psychoanalyst. Since the foundation of confidentiality is eliminated, the couples in the show are called ‘participants’ as opposed to ‘patients.’ Dr. Guralnik has very openly acknowledged the ways in which the sessions with participants differ from traditional therapy, stating the following in an interview in 2020: “So the confidentiality is suddenly taken out, in both directions. They get to see my conversations with Virginia and I get to talk about them and the whole world sees our work. But, the work is documented and recorded by a crew. And it’s like you sacrifice confidentiality but you get something that’s actually pretty amazing, which is that the people who are participating feel deeply held, respected, [and that] what they’re doing really matters and matters now. And there’s evidence that they did it” (Hill, 2020, para. 14). Dr. Guralnik expanded upon this further in a 2024 interview:  “The frame of confidentiality is usually sort of our first rule, right? I felt the same way when I first heard about this idea. But what excites me the most about what the show has been able to accomplish is that it manages to offer something to people that otherwise wouldn't have access to therapy, wouldn't have access to how other people work through their issues as relationship issues always emerge. There's a lot of really vital information that I think the series offers” (Chang, 2024, para. 6).

Ethical Questions for Reflection

Despite the show’s acknowledgement that individuals are not ‘patients,’ they still categorize what occurs as treatment, thus raising ethical questions worth examining from a professional standpoint. 

1. Multiple relationships and conflicts of interest

1. Ethics Code Standard 3.05, Multiple Relationships, encourages psychologists to avoid multiple roles that may have competing interests or obligations, and therefore undermine professional judgment (APA, 2017). Dr. Guralnik’s position is a complex one, as she is both a clinician and a public figure at the center of a popular TV series. For individuals on the show, she is in the role of clinician and a consulting producer (i.e., someone who has influence over what is or is not shown to the world on television and what is left on the cutting room floor). Though this does not represent ‘multiple relationships’ in the traditional sense, it introduces a new dynamic that likely influences how individuals interact with her during sessions.

2. Ethics Code Standard 3.06, Conflicts of Interest, asks psychologists to refrain from taking on a professional role when other factors, such as financial interests, could reasonably be expected to impair their objectivity, competence, or effectiveness in performing their functions as a psychologist (APA, 2017). Though the show is, again, not considered therapy in the traditional sense, and although it is clear Dr. Guralnik navigates her position with care, it is worth naming the multiple influences involved in the situation. There is the responsibility for beneficence and non-maleficence for the participants, and a pull from producers and investors for the show to continue producing content that will get views, two influences that may, at times, compete with each other. 

2.  Avoiding harm

1.  Ethics Code Standard 3.10 requires informed consent (APA, 2017). Yet, can participants fully anticipate, and therefore consent to, the possible emotional, relational, and social consequences of broadcasting their most intimate difficulties to millions of viewers, including work colleagues, family members, friends, and community acquaintances? For one couple who appeared on the show, the consequences following their season airing have been grim. In a 2025 article Brian Fishman wrote for The Guardian, he reflected on why he and his wife, Jessica, applied to be on the show, stating “I wanted to save my marriage. I was desperate for help” (para. 7). They found the therapy unhelpful and discontinued after only 4 sessions, as opposed to completing the planned 18 sessions. Mr. Fishman discussed in the article the significant backlash he has received online, including vitriolic comments encouraging his wife to leave him. He summarized his experience further, stating “The airing of the show, and the crude misrepresentations it has invited, have been a wrecking ball to our very fragile site of reconstruction. That the therapy didn’t help us feels like our responsibility as much as Dr Guralnik’s: we hardly gave it a chance, and at our level of distress we were very hard to help. But now it’s back to make our lives harder a second time. Couples Therapy has certainly helped others. But I deeply regret having applied to be on it” (para. 40).

3.  Media presence

1. Ethics Code Standard 5.04, Media Presentations, requires psychologists take precautions to ensure any public statements they make are based on their professional knowledge, are consistent with the Ethics Code, and do not indicate that a professional relationship has been established with the recipient (APA, 2017). Dr. Guralnik has clearly articulated throughout her interviews that what occurs on the show is not conventional therapy due to the lack of confidentiality. Though not traditional therapy, engaging with individuals on a show in this fashion certainly qualifies as a professional relationship. If the interactions do not fall under psychotherapy services, but do represent a professional relationship, then what does this mean regarding the application of professional ethical principles? With the increasing popularity of shows like Couples Therapy (Netflix released a version of its own, titled Blue Therapy), it may be worth having updated guidance for professionals operating in this new category of work - not quite ‘therapy,’ but certainly closer to therapy than anything else. 

Case 2: Podcast - Where Do We Begin?

Esther Perel is a Belgian therapist and bestselling author who specializes in relationships and has gained a significant following over the last decade since her podcast, Where Should We Begin? premiered in 2017. In her podcast, each episode features an anonymous individual or couple who completes a one-time session with Ms. Perel with the purpose of the session being released publicly, and participants are aware of this. The episodes are edited for time and anonymity, with names and identifying information altered or omitted. Throughout the episodes, Ms. Perel also pauses the session recordings to reflect on what she is thinking about in that moment in the session, resulting in a podcast that allows viewers an opportunity to listen in to the inner workings of a session and listen in on the therapeutic insight from a clinician’s perspective. 

Ethical Questions for Reflection

It’s important to note that Esther Perel is a licensed Marriage and Family Therapist (LMFT), not a licensed psychologist. Therefore, she is not subject to the Ethics Code (APA, 2017). However, licensed psychologists can benefit from reflecting on Ms. Perel’s career and work in the context of therapy in the media. 

1. The limits of anonymization

1. Ethics Code Standards 4.01, Maintaining Confidentiality, and 4.07, Use of Confidential Information for Didactic or Other Purposes, require that confidential information be sufficiently disguised so that individuals cannot be identified (APA, 2017). Though the main types of identifying information are kept confidential, individuals on the podcast often share intimate and specific information about their situation, relationship, cultural background, and life circumstances, that may be enough for individuals close to the participant to be able to identify them. 

2. Informed consent in a one-time session model

1. Ethics Code Standard 3.10 requires informed consent (APA, 2017). Consenting to the therapeutic process is often a topic that is returned to over time throughout the course of treatment when questions or concerns arise. However, the single-session podcast model does not allow the time and space for processing these concerns. Participants must consent at the outset, before they can fully know what they will be disclosing or how they will feel in the moments, days, and weeks following the recording. It may be beneficial for professional guidelines to consider how informed consent practices may need to be modified to accommodate and protect participants in these new platforms. 

Case 3: Social Media - Dr. Julie Smith

Dr. Julie Smith is a clinical psychologist in the United Kingdom. She is a New York Times bestselling author, and one of the most prominent mental health content creators on social media, with over 2 million followers on Instagram and nearly 5 million followers on TikTok. Dr. Smith’s social media presence has a notably different focus from the prior two cases in that she does not conduct or simulate psychotherapy. She focuses on delivering psychoeducation on a wide variety of topics, translating clinical topics to understandable and digestible short-form video clips. In this way, Dr. Smith’s work aligns with Guideline 1.1 in the APA Guidelines for the Optimal Use of Social Media in Professional Psychological Practice (2021, p. 7): “Psychologists are aware that social media can be highly useful for improving public access to information about behavioral health, psychological services, and the integration of behavioral health within primary, secondary, and tertiary health care.”

Ethical Questions for Reflection

1. The conversations will happen with or without us

1. Effective psychoeducation does require that complex clinical concepts be translated into accessible and understandable language, without distorting the information in the process. Given this is a practice psychologists engage in routinely in day-to-day work, psychologists may be particularly adept at creating digestible and accurate social media content. Although psychologists have an ethical duty to base their public statements in professional knowledge, training, or experience in accordance with psychological literature (Ethics Code Standard 5.04, Media Presentations), non-healthcare workers who create content do not necessarily hold their content to these same standards (APA, 2017). For example, Yeung et al. (2022) found that only 21% of TikTok videos about ADHD presented quality information. The authors also noted that the majority of misleading videos were uploaded by non-healthcare providers, and healthcare providers uploaded higher quality and more useful videos. Conversations and information (or misinformation) on psychological topics will continue to occur online with or without the input of licensed psychologists. On social media platforms where anyone can claim expertise, is it more beneficial than not to have licensed clinicians creating content that is empirically grounded to help balance out the tidal wave of inaccurate information on mental health? 

2. Supervision and professional accountability

1. Clinical work takes place within established systems of professional conduct, which help provide oversight and accountability for the practice of psychology. How much content creation for social media falls into or outside of these systems is still somewhat of a grey area. Although the APA’s Social Media Guidelines (2021) discuss multiple aspects of social media use, there are still many questions left unanswered. This is an area that remains to be explored by professional organizations, and on which clinicians would benefit from guidance given the ever-increasing popularity of content creation on social media. 

3. Self-disclosure and boundary management

1. One dynamic that Dr. Smith and other creators must contend with is the possible tension between a clinician’s online persona and their professional clinical relationships. Jeff Guenther, a Portland based licensed marriage and family therapist with nearly 3 million TikTok followers, stated “The weirdest part, for some clients, is seeing the therapist they know from their sessions inhabit this entirely different persona online. I’m not talking to my clients in a way of like ‘Here’s the top 10 reasons you should break up with your boyfriend’” (Lindsay, 2024, para. 13). The APA Social Media Guidelines (2021) address this aspect, recommending under Guideline 2.5 that psychologists discuss their use of social media as part of the informed consent process with clients. 

Conclusion - The Gaps in Professional Guidelines

In the three cases outlined above exploring psychotherapy in television, podcasts, and social media, a wide range of ethical questions arise. The clinicians discussed all engage meaningfully with the public, bringing clinical psychology into popular culture in new and raw ways. Each of these cases create many questions that ultimately lead back to the main problem:  Is the existing APA Ethics Code fully equipped to handle these new situations? 

The Ethics Code (APA, 2017) is broadly written in a way to be able to lend itself to a variety of changing contexts, and as we outlined above, many of these standards are clearly applicable to therapy-in-media contexts. APA’s 2021 Social Media Guidelines also offers clinicians newer guidelines on social media use specifically. Yet, large gaps remain, leaving many ethical grey areas for what is or is not above board about the way psychologists currently interact with media platforms. The opening story reminds us of what is at stake for clients when individual clinicians are left to exercise professional judgment in an ethical vacuum. When a client is scrolling social media and has to ask herself if her therapist is speaking about her in a video projected to millions, that is going to have a negative impact on the client’s experience of therapy and could have significant negative impact on the client’s mental health, regardless of whether the therapist was actually referencing her. Psychology owes its professional members, the clients those members serve, and the public clearer guidance on how to ethically navigate therapy when it moves from couch to screen. On that front, there is good reason for optimism: the APA Ethics Code Task Force has been hard at work taking into consideration the 2,600+ comments they received in response to the recent revised draft of the Ethics Code (APA, 2026). A new draft is anticipated to be completed in 2026, which will hopefully continue to increase the thoughtful, technology-forward guidance our field, members, and clients deserve (APA, 2026).  

References

American Psychological Association. (2026, February). Ethics Code Task Force. https://www.apa.org/ethics/task-force

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct (2002, amended effective June 1, 2010, and January 1, 2017). https://www.apa.org/ethics/code/ 

American Psychological Association. (2021). Guidelines for the optimal use of social media in professional psychological practice. https://www.apa.org/about/policy/guidelines-optimal-use-social-media.pdf 

Chang, A. (2024, June 7). TV series 'Couples Therapy' gives viewers a rare look into real life therapy sessions. NPR. https://www.npr.org/2024/06/07/g-s1-3018/tv-series-couples-therapy-orna-gurlanik 

Fishman, B. (2025, September 14). My wife and I had couples therapy on TV. It nearly wrecked 

our marriage. The Guardian. https://www.theguardian.com/lifeandstyle/2025/sep/14/my-wife-and-i-had-couples-therapy-on-tv-it-nearly-wrecked-our-marriage

Guralnik, O. (n.d.). Couples therapy docuseries.  

            https://www.ornaguralnik.com/couples-therapy-docuseries-copy 

Hill, L. (2020, June 18). Dr. Orna Guralnik and 'Couples Therapy' can help your relationship. IndieWire. https://www.indiewire.com/awards/consider-this/dr-orna-guralnik-couples-therapy-emmys-1202238518/ 

Lindsay, K. (2024, April 30). My therapist is a TikTok star. Bustle. https://www.bustle.com/wellness/my-therapist-is-a-tiktok-star 

Yeung, A., Ng, E., & Abi-Jaoude, E. (2022). TikTok and attention-deficit/hyperactivity disorder: A cross-sectional study of social media content quality. The Canadian Journal of Psychiatry, 67(12), 899–906. https://doi.org/10.1177/07067437221082854