A paper came across my twitter timeline recently which genuinely left me wide eyed with surprise. It was entitled “Should psychiatrists Google their patients?” It was one of those questions which seemed to me could only have the answer no, and I was shocked the paper had even been written. Reading it, and the accounts of some service users on twitter, caused me even more disquiet.
Our interconnected age
It is most certainly the case that we live in an interconnected age, where a variety of social media platforms encourage varying levels of intimacy, or a performance of intimacy with people all over the world. Whilst we may feel there is little disconnect between our public, online self, and private, offline self, research consistently shows we curate our media presence. We are all now our own PR officers, paid in likes and favorites.
With this being the case it is almost certain that anyone who comes into contact with mental health professionals will have some kind of social media presence. However simply because a professional can do something does not mean they should.
Boundaries and Barriers.
The management of appropriate boundaries is something which every therapist has to be skilled at. In a relationship where one person is vulnerable and the other is not (to paraphrase Rodgers) the therapist has a huge responsibility to manage the boundaries. Good boundaries not only keep client and therapist safe but help to build trust.
If a client asks you to read a blog because it explains something, or gives an insight into their world you are invited in. If you google without permission and find the same blog you are not only crossing a boundary but you may be erecting a barrier to trust and meaningful communication.
Imagine the difference between a client bringing their diary into a session and asking you to read from it, and you taking it from their bag and reading it whilst they used the bathroom. The latter is an invasion of privacy, and a breach of trust. Furthermore what are you going to do with the knowledge you have surreptitiously obtained? If you bring it up you will have to admit you broke a very clear societal boundary, and violated the clients privacy. It may well colour your attitude towards the client, creating another barrier to trust and building of the therapeutic alliance. It is always a question of how honest a client is being. The BJpsych piece details a number of scenarios where a client may be being untruthful, and suggests social media may help with this. Not once does it ask why a client may not be being totally honest, or what this actually tells us about them, their state of mind and their relationship with mental health professionals.
I realise that psychiatrists are not therapists, they do not have to build trust and have either unconditional regard or a non judgemental attitude. All I will say here is that after talking to numerous service users perhaps they should.
On the Radar.
A particularly worrying section of the piece was devoted to the idea of monitoring a patient’s social media for suicidal ideation. I shall quote this in full.
Consider a long-term patient with severe depression, who has regular appointments with a community psychiatry team. Could someone from the mental health team monitor the patient’s mental state via their social media feed or blog, with their consent? Assuming people write honestly and use the same websites regularly, social media can give a unique, time-relevant insight into a person’s mental state. For example a Facebook ‘status’ or a ‘tweet’ on Twitter might often include information about how a person is feeling. The posting of certain pictures and videos or even ‘emoticons’ (cartoon faces depicting different emotions) might also reveal important insights into the patient’s current frame of mind.
Clearly, if psychiatrists were to monitor mental state in this way, it would fundamentally change how mental health systems work, but it is not as far fetched as it sounds. It would not necessarily involve a person constantly watching the millions of messages streaming via a forum, Facebook or Twitter feed, which would clearly be impossible. The technology to automatically flag the use of certain phrases in emails or on social media already exists, and a team at Dartmouth University in the USA, involving computer scientists and psychiatrists are developing this technology to help prevent suicide, as part of The Durkheim Project.24
I have highlighted the sentence in bold.
Yes, we know the technology exists. We also know just how people with mental health difficulties reacted to Samaritans Radar and its attempt to mine peoples social media for certain terms. One of the strongest objections, explained very well here by @BipolarBlogger was that what looks like “a cry for help” is often self care. Social media provides an instant support network for someone in distress, and with whole communities gathered around hashtags and topics becomes a vital outlet. For example a tweet along the lines of “Feeling really bad today, #SH thoughts, everything bleak #PNDchat” may look to someone unfamiliar with the varying way twitter is used like immediate intervention is needed. However it can be interpreted as “I am feeling really bad today and concerned I may self harm as everything seems really bleak. Is anyone from the post natal depression community online who I can talk to while these feelings pass.”
If service users fear their honesty about how they feel may be used by those with power and authority against them, they lose a lifeline which provides support and community. I have actually discussed with clients how using social media to express their feelings between sessions can be a useful self care tool.
There is an issue here with looking at, rather than engaging in, the curated personas of social media. An individual may use social media as a tool where they manage their mental health. The BJPsych piece instead seems to posit all service users as simply posting streams of consciousness without any control or curation. (I am aware that some conditions may mean someone has more limited cognitive function, or understanding. However even someone in the grip of a manic episode is an adult not a child, and should be treated as one).
The whole tone of the “Should Psychiatrists Google…” piece for me was paternalistic in the extreme. There seemed to be an idea that mental health professionals should know all aspects of their clients lives, not by building trust, but as a right. Furthermore it placed psychiatrists as intrinsically good, ethical and never abusive. We simply need to look at the literature and news to see this is not always the case. By blurring the boundaries between professional and personal they intrude themselves into clients lives. This intrusion is often used by those who would abuse to “groom” vulnerable adults. It struck me that in the section on vulnerable adults they discussed how someone may have put their address on social media, and need warnings against this, but not how those with power in our society have frequently preyed on the vulnerable. It is those professionals who have blurred the boundaries who so often go onto to abuse those who are supposed to be in their care.
Another aspect of paternalism is the suggestion that Googling may show up if a patient/client is behaving in a manner the professional finds acceptable. The idea that doctors themselves are saints who never drink, smoke, have unprotected sex, misuse medication or in any way stray from some 1950s ideal of how people should behave is not only laughable, its dangerous. All to often minority groups have been pathologised by members of the medical community who sought to declare their behaviour unnatural or unhealthy. The GSD community has been a particular target of this. Say for example a medical professional finds a blog that has pictures of a patient engaged in BDSM or tweets about attending gay saunas. It would be all too easy for their own prejudices against such behaviour to colour their perception of whether this was “normal” or “healthy” Indeed many members of minority communities conceal their sexual behaviour from doctors, including mental health professionals, because of the experience of being treated negatively if they disclose.
For psychiatrists to ignore the very real prejudice that exists, or to believe they are above it strikes me as naive in the extreme. The “Complicated” report found that 48% of bisexial people had experienced biphobic treatment from medical professionals in the UK. Other GSD groups face similar treatment, and have their own reasons for not disclosing their gender and or sexual identities to medical staff.
Should clients Google mental health professionals?
I feel I cannot write this without addressing the reverse, should clients use Google? I feel not only that they should, but when it comes to therapists, they must. Sadly the lack of regulation of therapy in the UK means anyone can call themself a therapist. As it stands Googling to see if there are any complaints about an individual, if their claims around qualifications and experience are accurate is the best way to ensure the therapist is who, and what they say they are. Furthermore by looking over blogs, social media feeds and articles a potential client can see if this is the therapist for them. Whilst often a client has no choice of therapist, if they are receiving counselling via the NHS or a charity, in private practice at least they can exercise their choice. The importance of the therapeutic relationship means that seeing if you might click is time very well spent.
I can see no reason not to Google other medical professionals, often service users have forums and boards, where bad practice (or good) is disclosed long before the slow wheels of bureaucracy grind into action over formal complaints procedures.
Of course there is still the need to manage boundaries. I have a social media policy as part of my contract. I have set my facebook to private, and expect that to be respected. Should a client send a facebook request I would bring that into a session, exploring the need to see me in a family, non therapeutic setting. At the same time I make explicit how twitter, instagram and other social media platforms are seen by me as public spaces, and what that means for the client/therapist relationship. For example, I will never discuss the content of a counselling session on social media, even if explicitly invited to by a client, just as I would not if I bumped into them on the street.
Whilst psychiatrists and therapists have different roles I do not believe they are so substantively different as to make Googling a patient/client acceptable, ethical or safe. The harms are too great, too wide ranging and too unacceptable for it to be done. The damage to trust, the potential for abuse, mistakes, mistaken identity, misinterpretation and prejudicial content which could arise all seem very clear to me. If there is currently no guidance on medical professionals googling patients then it must be written, and it must be written from a patient/client centered viewpoint.