Challenges Faced by Psychiatrists in the Internet Age

In January of my third year of medical school while attempting to study for my medical licensing examination, I began a blog. (Any distraction from learning about the Krebs cycle was heartily welcomed!) Within a week, I had posted photos of my family members, criticized an episode of ER, and griped about my studies. A social addict, I was hooked on this self-disclosure.

As I continued my medical studies, however, I began to ponder the implications of posting personal things-especially after a resident who interviewed me for residency mentioned that he found my blog and commented about my photographs during my interview.

Less than a month into my intern year, I inexplicably received an e-mail from someone from out of state who divulged that he had been treated for mental illness in the past. He had not been my patient; he was just pleased with the mental health care he had received. Unsure of what to do, I replied with a simple one-line e-mail, and thanked him for reading the blog.

My response seemed to give him the green light to leave frequent comments on my blog posts. He e-mailed me again a few months later, asking for book recommendations, and he became angry when I did not reply immediately. I eventually turned on the option to approve or reject comments before they are posted. This greatly offended my blog reader who posted angry comments on my blog entries, which were followed by apologetic comments pleading with me to contact him and to reassure him that it was okay for him to read my blog.

This experience was certainly frustrating and a bit frightening. I continued my blog throughout my intern year because my schedule was too hectic to keep up with all my friends. My blog was a great way to update friends and family about my life without having to send regular mass e-mails. At first it was fun to have strangers read and comment on my blog, but my experience with the patient from out of state was disquieting and I started to wonder what might occur if one of my own patients found my blog.

As a psychiatrist, I do not divulge information about my private life to my patients, but some of my patients might wish to know more about me. But my blog offered many personal details about my life. . . . I discussed my work, the movies I’ve watched, my relationships, and even which antidepressant my cat was named after.

It felt unfair that while the rest of America was able to blog casually, I had to protect my privacy. Then came Facebook. Started at Harvard University in 2004 to give university students the opportunity to expand their social network, Facebook rapidly grew, eventually allowing anyone over the age of 13 to join. Today, Facebook has more than 250 million worldwide active users (almost half of whom visit daily).

Facebook has garnered a lot of attention in the media recently, and with each passing month the implications of what this Web site means for our society are studied with greater and greater scrutiny. The New York Times Magazine recently explored the consequences of the new society that this social network creates, and how many are beginning to escape it.¹ In a recent New England Journal of Medicine article, an intern pondered how to maintain professional boundaries when patients request a doctor’s Facebook friendship.² This issue is even more complex for psychiatrists.

I had ignored requests to join Facebook until a friend sent me a link to a photo album that I was unable to see unless I registered. I joined, set up my profile, and found a few friends who were already using the site. My friend list began to grow. I was delighted to see such organization. By simply clicking on the title of a friend’s favorite movie, I was quickly able to see which of my other friends also felt that to be their favorite movie. Never before was such a wealth of banal trivia about my friends so easily accessible!

As the popularity of Facebook grew, so did my list of friends, and my blog suffered as a result. When I uploaded photos on my blog, I was required to tweak the programming language to ensure that the photo was positioned where I needed it to be, with my comments where I wanted them. On Facebook, however, my photos and comments could easily be posted after a few short clicks. My friends commented on my photos and thoughts on Facebook far more often than they ever did on my blog.

Facebook has warped the way that information spreads. The site allowed me to learn when old friends got engaged or were expecting a child. But it was through Facebook that I learned that my ex-girlfriend had started dating again. Facebook has also given people a place to grieve. After my nephew’s best friend died in a car crash, his friend’s wall became an Internet memorial, where over 275 Facebook friends continue to leave comments of sympathy and loss more than a year later.

What implications do Web sites such as Facebook have on the doctor-patient relationship? Recent data show that about 10% of people in the United States take antidepressants,³ while almost 25% have a Facebook page.⁴ Therefore, a new patient is two and a half times more likely to be on Facebook than to be on an antidepressant. With such rampant use of the Internet and all its interactive features, we would be remiss as psychiatrists to not incorporate Internet habits into our history taking. Much like asking a patient about substance use or sexual history, once such subjects are broached by the therapist, the patient learns that such topics are not taboo and that they can and should be openly discussed.

These are 21st-century issues that our patients will also struggle with. My first psychotherapy patient was an architecture student who was anxious about the fact that he kept using Facebook to meet and seduce women. A middle-aged teacher lamented to me the stress she had endured after she declined a Facebook friendship request. A young female accountant, suffering from significant social anxiety and low self-esteem, told me she felt like a fraud when friends tagged her in a photo or commented on her Facebook wall.

While I do not tell my patients that I have a Facebook account or that I had my own social struggles with it, I have been able to use my knowledge of this Web site to press patients for more information using Facebook jargon. For example, I knew to ask, “How does it feel when someone tags a photo of you?” and “Do you comment on other people’s walls?”

It has become nearly impossible to hide oneself from Google . . . a clever combination of key search words can pull up a lot of personal information about any mental health professional. Patients who are curious about us will very likely turn first to the Internet. Do we want our blogs and Facebook profiles to be the first pages that come up?

And how do we respond when a patient asks us to read their blog? Should we shy away from this? Is this request any different from reading a poem a patient wrote about his or her depression, or a letter that a patient is planning to send to his estranged child?

As psychiatrists, we strive to preserve anonymity with our patients. But as human beings in the Internet era, we are faced with a wealth of tempting electronic venues to share our lives. The problem is that by putting personal information for friends on the Internet, we also share our personal information with the world.

References:

References

1. Heffernan V. Facebook exodus. New York Times. August 30, 2009:MM16.
2. Jain SH. Practicing medicine in the age of Facebook. N Engl J Med. 2009;361:649-651.
3. Olfson M, Marcus SC. National patterns in antidepressant medication treatment. Arch Gen Psychiatry. 2009;66:848-856.
4. Facebook statistics. http://www.facebook.com/press/info.php?statistics. Accessed March 2, 2010.