Information technology in the 21st century has brought dramatic changes to psychiatric practice and psychotherapy. There are many new possibilities and patterns for information use and for communication, as well as new ethical, legal, and clinical problems for the psychiatrist. One can ask how the Internet shifts standards of care required from therapists and whether ethical guidelines should change.
The same boundaries and ethical standards concerning the patient-psychiatrist relationship that existed in the 20th century still apply in the 21st century. While some of the conditions under which boundaries apply may be quite different, such as the potential speed of mutual communication provided by e-mail, the theoretical concepts defining boundaries remain the same. Maintaining confidentiality is an ethical duty for psychiatrists, protected by law. Communications between therapist and patient are privileged, and informed consent is needed to share any information about a patient.
A physician is a fiduciary to his or her patient. A fiduciary relationship exists when one person—the professional—accepts the trust and confidence of another person—the patient—and agrees to act only in the patient’s best interest. Acting in a patient’s best interest requires a professional to refrain from all behaviors that may present an unreasonable risk of harm to the patient.1 In the American Psychiatric Association’s Principles of Medical Ethics, Section 1, a psychiatrist’s first duty is to do no harm. These standards have not changed with the advent of Google, e-mail, social media, or other Internet communications.
In this article, we consider some of these technologies and recognize that there will always be new technologies.
Expect that your patients will Google you. Google yourself to see what you find. Should a therapist Google a patient? When patients post information on the Internet, it becomes public and is not protected. The psychiatrist may want to Google a patient to check whether the patient is delusional or has a criminal record, or to find out what medicines the patient might have taken in a suicide attempt. This is permissible legally—but is it ethically and clinically permissible?
In May 2009, Psychiatric News answered a query from a reader questioning whether it was ethical to Google patients: “We have learned that our psychiatry residents routinely ‘Google’ their patients. . . . Is it ethical . . . ?”2 The editors of Psychiatric News responded:
“Googling” a patient is not necessarily unethical. However, it should be done only in the interest of promoting the patient’s care and well-being and never to satisfy the curiosity or needs of the psychiatrist. Also important to consider is how such information will influence treatment and how the clinician will ultimately use this information. Psychiatrists should consider these questions before resorting to a Google search.2
The answer also cautioned clinicians that information obtained from a Google search cannot be verified as fact. Although the information provided by Google about a patient may be useful, the information may not be current or accurate, especially for clinical purposes.
Dr M, a resident at a university hospital, reported to her supervisor that she had Googled a patient to verify whether information he had presented in the clinical examination was accurate or delusional. The patient reported that he was a famous author and an authority on posttraumatic stress disorder. Dr M found the patient’s multiple publications via a search on Google. Apparently, Dr M also learned that the patient had been involved in a number of drunk driving incidents and had an ethical charge relating to boundary violations.
Dr M’s dilemma centered on what to do with the information uncovered in the search. She did not know whether to confront the patient with the information or to ignore it because it was not relevant to the patient’s current clinical situation.
The doctor needs to let the patient know that a Google search was done, and then she has to discuss the re-sults with the patient. Material found on the Google search can come from any public record, such as police records.
E-mail certainly offers an additional means of communication and provides access to care for the patient. The use of e-mails can save time and solve the problems of missed calls. E-mails provide a relatively easy way to request and change appointments, order prescription refills, and handle other administrative issues. However, they may be sent and responded to without regard to time and place.
While e-mails may be helpful for administrative purposes, they are not a helpful treatment modality, even when combined with face-to-face therapy. As a general rule, e-mail is not secure: e-mail may be misdirected to the wrong person and read by unintended recipients. The potential number of people who may have access to e-mails poses many confidentiality and privacy problems.
Using e-mail as a therapeutic tool also poses many problems. Questions of reimbursement arise as well as those of confidentiality and security.3 The Health Insurance Portability and Accountability Act (HIPAA) applies whenever there is electronic transmission of personally identifiable health information.4 The use of e-mail can increase the risk of breach of confidentiality and violation of HIPAA. The psychiatrist should review with the patient the use of firewalls, passwords, antivirus software, and encryption.5
Boundaries of time and place provide a secure therapeutic framework that encourages stability and predictability. While the flexibility of time and place provided by e-mail may make communication easier, it also increases the risk of extending the sessions and disrupting or blurring the therapeutic frame. Moreover, because there are no visual or verbal clues, communication by e-mail may be misconstrued. The rapidity and intensity of e-mail makes familiarity more likely; therefore, transfer-ence and countertransference may be increased.6 Sometimes, there is role reversal.
The use of e-mail may result in boundaries being crossed; it is easy to go from professional communication to the personal. The exchanges may include discussions about books, operas, restaurants, plays, sporting events, health and exercise, and even the frustrations of the therapist with family or other patients; vacation photos may be shared. In some cases, the patient becomes the caregiver of the therapist.
In addition, patients can become consumed and preoccupied by e-mails to and from their therapists. A short sampling of 4 cases reveals a similar pattern. In these cases, there were some 1000 to 3000 e-mails sent between patient and therapist over 3 months to 2 years. Patients described their reactions:
• Patient A: “E-mailing is very intense . . . more so than face-to-face sessions. . . . I keep the e-mails and go over them repeatedly.”
• Patient B: “E-mailing with my therapist is very exciting . . . it is all-consuming. I feel such a strong connection. . . . I am glued to the computer.”
• Patient C: “It takes all my time . . . I read them over and over. . . . I am waiting for a response. I am careful not to let my husband see the e-mails.”
• Patient D: “I am tied to the computer like an addict, waiting for a response. I spend time thinking about my response and what will interest him.”
Although none of the cases involved a sexual relationship, the patients developed a strong attachment to and dependency on their therapists. When the therapists wanted to stop the e-mails, the patients felt abandoned.
Consequently, legal issues ensued. Expert opinion in each case found that the treatment fell below the acceptable standard of care. The patients had kept the e-mails and there was a perfect record of what happened. The e-mails were admissible as evidence in civil cases and board hearings. Eventually, the patients were successful in recovering monetary damages.