By Dana Scarton
Special to The Washington Post
Tuesday, March 30, 2010; HE01
As his patient lay unconscious in an emergency room from an overdose of sedatives, psychiatrist Damir Huremovic was faced with a moral dilemma: A friend of the patient had forwarded to Huremovic a suicidal e-mail from the patient that included a link to a Web site and blog he wrote. Should Huremovic go online and check it out, even without his patient's consent?
Huremovic decided yes; after all, the Web site was in the public domain and it might contain some potentially important information for treatment. When Huremovic clicked on the blog, he found quotations such as this: "Death makes angels of us all and gives us wings." A final blog post read: "I wish I didn't wake up." Yet as Huremovic continued scanning the patient's personal photographs and writings, he began to feel uncomfortable, that perhaps he'd crossed some line he shouldn't have.
Across the country, therapists are facing similar situations and conflicted feelings. When Huremovic, director of psychosomatic medicine services at Nassau University Medical Center in New York, recounted his vignette last year at an American Psychiatric Association meeting and asked whether others would have read the suicidal man's blog, his audience responded with resounding calls -- of both "yes!" and "no!" One thing was clear: How and when a therapist should use the Internet -- and even whether he or she should -- are questions subject to vigorous debate.
"We are just beginning to understand what ethical issues the Internet is raising," says Stephen Behnke, ethics director for the American Psychological Association. "To write rules that allow our field to grow and develop and yet prevent [patient] harm at the same time: That's the challenge."
In fact, the tremendous availability online of personal information threatens to alter what has been an almost sacred relationship between therapist and patient. Traditionally, therapists obtained information about a patient through face-to-face dialogue. If outside information was needed, the therapist would obtain the patient's consent to speak with family members or a previous mental-health practitioner. At the same time, patients traditionally knew little about their therapists outside the consulting room. Now, with the click of a mouse, tech-savvy therapists and patients are challenging the old rules and raising serious questions about how much each should know about the other and where lines should be drawn.
Among the questions under debate:
Should a therapist review the Web site of a patient or conduct an online search without that patient's consent?
Is it appropriate for a therapist to put personal details about himself on a blog or Web site or to join Facebook or other social networks?
What are the risks of having patients and therapists interact online?
Neither the American Psychiatric Association nor the American Psychological Association has rules specifically governing therapists' online behavior, but ethics advisers with the psychiatric association maintain that online searches are not wrong -- as long as they're done in the patient's interest and not out of therapist curiosity.
Many therapists contend it's more important to discuss such questions than it is to dictate behavior. "It's not whether a particular application is right or not," says Sheldon Benjamin, director of neuropsychiatry at the University of Massachusetts Medical School in Worcester. "It's whether you do it mindfully -- whether you understand how it changes the doctor-patient relationship."To Google or not
Benjamin, 53, swears by his iPhone and enthusiastically tells of sampling the Internet in its infancy. At the same time, Benjamin, who directs psychiatric training at UMass, advocates caution when it comes to mixing the Internet with therapy.
He says he has never searched a patient's name online and worries that doing so could dilute the therapeutic process by bringing in information from outside the patient-therapist discussion. When patients have asked Benjamin to read their blogs, he has agreed, with one caveat: that he do so during a regular counseling session. "Even if you brought me a disability form, I'd fill it out in the room with you," says Benjamin. "I was taught to make the time with the patient the time when the work is done."
Suena Massey takes a different approach. Massey, 35, an assistant professor of psychiatry at George Washington University Medical Center, considers Googling a patient a valuable professional tool. "One of the duties of a psychiatrist is to corroborate what patients say," Massey explains. To that end, online searches can be helpful when traditional approaches -- obtaining the patient's consent to contact his previous psychiatrist or family members -- are not available.
One such case involved a patient who presented with symptoms of mania, a component of bipolar disorder. The man claimed to be well connected in Washington. After their meeting, Massey typed the patient's name into a search engine. Up popped postings suggesting that the man's claims were accurate. In a subsequent session Massey told her patient she had Googled him, and he was okay with it. She ended up treating him for bipolar disorder; had his claims been false, she says, she would have considered his condition to be more severe.
Massey says she will warn a patient about her possible use of Google searches if she thinks the patient might have a problem with it. "You could almost make the argument that it's negligent not to search online when there is public information available" and it might help treat a patient, she says. "If you're just looking things up out of personal interest, I think most doctors would feel uncomfortable with that."Public vs. private
But what happens when the circumstances are reversed? What happens when a patient seeks information about his therapist online or pursues a relationship with his therapist on Facebook, MySpace or via another social network?
Most therapists are not alarmed by the idea of a Google search. "I know my patients Google me," Massey says. "I think it's their right as consumers." Some providers anticipate such searches by maintaining Web sites detailing their professional qualifications.
However, there can be problems when personal details are available. Take the case of a man who, after developing romantic and erotic feelings toward his therapist, typed her name into a search engine and found a Web site featuring personal photographs of the therapist, including a bathing-suit shot.
The man quit treatment and reported the discovery to Behnke's office. "He knew the image of his therapist in her bathing suit was going to be so present to him that he wouldn't be able to concentrate on his psychotherapy," Behnke explained in a telephone interview. "There was material on the Internet that had an impact on this psychologist's clinical work."
Behnke cautions therapists to assume that most clients will conduct online searches, and he urges them to make sure they remain vigilant about what gets posted.
Although most therapists say it's inappropriate to have relationships with patients via social networks, there is little agreement on whether it's okay for therapists to join such sites, and, if they do, just how private their information should remain.
For Huremovic, 39, social network abstinence is safest. "I have an understanding that if you choose to be a psychiatrist and a psychotherapist that you have to be very private in other parts of your social being," he says.
But some therapists, especially younger ones for whom using the Internet is a way of life, don't share this view.
For instance, psychologist Stephanie Smith, 35, has a Web site, and she has a presence on Twitter. Smith tweets to market her Colorado practice and to allow colleagues and other interested parties to monitor happenings in psychology. Typical posts provide tips for managing stress, announce a recent study's findings or refer followers to psychology blogs. Smith, who says Twitter has increased traffic to her professional Web site, admits to the rare tweet about her children or celebrity news.
"It's my style, but I know some people would not be comfortable" with her disclosure of nonprofessional information, she says.
Smith also has a Facebook account for her personal life. After teenage patients discovered that account and sent her "friend" requests, Smith enacted a policy forbidding past or current clients from engaging her online. She informs new clients of the policy and obligates them to comply.
This is the type of problem that UMass's Benjamin wants to avoid. "To me, it's a much bigger issue than bumping into a patient in a restaurant," he says. "You're putting out there, 'Hey, these are my contacts.' And someone then wants to enter your social circle. It puts you in a position where you must take a stand."
Keely Kolmes, a California psychologist who writes and lectures on Internet ethics, recommends that therapists make clear distinctions between their professional and personal lives online. "Younger clinicians get the Net but don't completely understand ethical and boundary issues that can come up," she says.
A former computer consultant, Kolmes, who is in her early 40s, goes to great lengths to keep her lives separate. On her personal Facebook account, for instance, she does not use a photo of herself on her profile page and she doesn't make reference to her professional name. She also restricts her public tweets and blogs to news of a professional nature. Still, she recognizes that any online sighting of one's therapist changes the dynamic for a patient.
"A lot of patients really want to think about you as existing in just that one space [of the therapy room,] and suddenly they're seeing you on Twitter and blogging," she says. "They can see that you're online at night posting things. I realize my choice to do that suddenly shifts my relationship with them."
Scarton is a Washington-based freelance writer specializing in health and medical matters.