Social media's challenges for psychiatry
Authors: Paul S. Appelbaum, Andrew Kopelman
Journal: World Psychiatry (2014)

The evolution of the Internet to include user-generated content, often referred to as Web 2.0, has altered our basic notions of privacy, connectivity, and communication. As more people are tweeting, blogging, posting on social media websites, and uploading personal videos, one consequence has been the blurring of boundaries between social and professional spheres. Whether as users of data posted by others or creators of information that others can access, psychiatrists are full participants in the social media revolution, creating a complex set of practical and ethical challenges for psychiatric practice. Patients increasingly turn to the Internet to learn about their conditions, physicians, and treatments 1. Once online, they find not only health-related and professional information, but also the social "digital footprints" of their doctors. Physicians similarly have new access to the personal lives of their patients, including the potential to acquire information that patients have not revealed directly and may not want them to have. Here we consider some of the ways in which Internet-based social media may impact psychiatric practice, and address some of the issues that arise when psychiatrists consume and produce social media content. Social media may be rich sources of collateral data that can be helpful in the diagnosis and management of psychiatric disorders, especially given the unreliability of information gathered in clinical interviews 2. Examinations of Facebook pages have shown the frequent inclusion of detailed, publically accessible postings describing depressive symptomatology 3 and ongoing patterns of substance abuse 4. Case reports have already demonstrated the potential clinical utility of web-based information for psychiatrists, for example altering the risk assessment for a suicidal patient in the emergency room 5. Indeed, persons with psychiatric disorders may be overrepresented among those who frequently self-disclose online. For example, the Youth Internet Safety Survey of 1501 respondents aged 10-17 found that the 5% of subjects who reported symptoms of major depression spent more time online and were more likely to post identifiable information (if they were male) and pictures (if they were female) than those without depressive symptoms 6. Other studies have suggested that excessive Internet use may be correlated with social anxiety, depression, and introversion 7. What should concern psychiatrists about pursuing the information newly available on social media sites and elsewhere on the Internet? As a foundational matter, the assumption that information on the Internet is necessarily accurate is clearly unwarranted. Researchers have demonstrated that people more readily engage in role-playing and fantasy in online user-generated content 8. These behaviors may be heightened by the "online disinhibition effect", promoted by the asynchronous nature of online communication, the minimization of centralized authority, and the increased anonymity inherent in the social framework of the Internet 9. Even if such information is accurate, however, there are other concerns about psychiatrists accessing their patients' digital footprints, most notably intrusion on areas of patients' lives that they may consider off-limits to their therapists. The intrusiveness of accessing data from social media without patients' consent might be thought to be mitigated by patients' seemingly public behavior in posting the data on readily viewed, unrestricted websites. But a survey of 492 bloggers demonstrated that people often disclose information online with a particular audience and time period in mind, even though the information may then become broadly available for an indefinite period 10. Misguided motives are another concern with regard to searching for patients' information. Mere curiosity, voyeurism or even self-interest may lie behind online searches. A case report of a psychiatrist assessing the financial status of a patient who was not paying his bill by looking at his house on GoogleEarth illustrates the self-serving impulses that can underlie attempts to access information about patients 11. Finally, psychiatrists may not have thought through how they intend to use online information about patients. If the therapist wants to use the information in treatment, for example confronting a patient about continuing substance abuse documented on a social network site, its source presumably would need to be disclosed. The consequences of such revelations may be difficult to anticipate, but reflecting on how a psychiatrist would feel if a patient had surreptitiously accessed similar personal information might suggest an answer. If not disclosed, one might wonder about the corrupting effects of concealed knowledge on their interactions, especially in ongoing psychotherapy. In sum, caution is called for in accessing patients' data online, especially sensitive personal information likely to appear on social media sites. Psychiatrists should be clear about how the information will benefit patient care, and a plan for use of the information should be thought through in advance. Given the intrusion on patients' privacy, consideration should be given to getting patients' consent. Similar to other medical interventions, perhaps this requirement for consent should only be waived in an emergency situation where acute safety concerns are paramount. And, of course, before any use is made of the information obtained, its probable accuracy should be taken into account. Psychiatrists and other physicians now also have a presence on the web, including in social media. This presence is complemented by patient-produced content about physicians, e.g., websites compiling patients' reviews of their doctors 12. However, the content of postings by physicians, medical students, and other health care providers is often problematic. An examination of 271 blogs written by physicians and nurses found that 42% described patients and 18% described them negatively. Of those describing patients, 17% were judged to contain sufficient information for patients to recognize themselves or their doctors, and three blogs included recognizable photos of patients 13. In 2013, a cohort study of the Facebook pages of 200 senior medical students applying for a competitive residency match revealed that 16% of these pages contained unprofessional material clearly at odds with accreditation guidelines 14. To what extent should patients' potential access to online information shape psychiatrists' use of social media? Disclosure of patient-related information, even when patients are not directly identified, can raise doubts among the public about the privacy of their medical interactions, increasing their reluctance to speak frankly with their physicians. When postings include negative comments about the healthcare system in general or a particular facility, they can shake patients' trust in the medical system and deter them from seeking care. Additionally, content showing doctors and other health professionals "behaving badly" may call their clinical judgment into question, raising doubts in patients' minds about the quality of the treatment they will receive. Such behavior can have negative consequences for the psychiatrist, including discipline by licensing boards 15. Unreflective and excessive self-disclosure by psychiatrists, especially when they are engaged in psychotherapy, is another concern inherent in their use of social media. The model of the therapist as a "blank slate" dates back to Freud, who depicted the ideal analyst as "opaque to his patients and, like a mirror, [showing] them nothing but what is shown to him" 16. Though today various schools of psychotherapy embrace different approaches to self-disclosure, almost everyone agrees that disclosures should be rare, time-limited and made only when they are likely to have a positive therapeutic impact 17. In general, online disclosures lack most of these properties. Crucially, the psychiatrist may be wholly unaware if and when any self-disclosure has occurred, and therefore never be able to address its significance with the patient. At the extreme, involvement in social media can contribute to a breakdown of boundaries in the physician-patient relationship. When medical professionals accept the offer of a patient to become their online "friend", the boundaries between the personal and professional become blurred 18. The terminology itself suggests that a transition in the relationship has occurred. Although it is easy to focus on the negative consequences of social media for psychiatry, the positive role that these media can play ought not to be neglected. In addition to being used for social interaction, social media offer an opportunity for psychiatrists and other physicians to form groups of health professionals with similar interests; share resources with colleagues (e.g., the SlideShare website, which allows users to upload and share Powerpoint presentations and other educational materials); collect research data; and disseminate useful medical information to the general public (e.g., creating Facebook pages for education and discussion regarding specific psychiatric syndromes). Thus, it is not at all clear that abstinence is the right answer to the challenges presented by the social media. We believe strongly that physicians do not have to shun social media so long as they use them prudently 19. Cautious online behavior includes taking advantage of appropriate privacy settings, which implies having a good reason for making personal information generally available. Equally important is the avoidance of unprofessional content, with the consequences that it can have for current and future patients and its liability implications for psychiatrists themselves. As a general rule, it may be helpful to ask oneself the question: "How comfortable would I be with my patients viewing this information?". Pejorative comments about facilities or patients have no place in social media. Not only should psychiatrists be aware of the content they have posted and to whom it is available; they should routinely scan the web for information about them posted by others, which may be inaccurate or overtly malicious. With these precautions, which should be inculcated as part of psychiatric training 20, the twenty-first century psychiatrist should be able to be a cautious but vigorous participant in the social media revolution.