Psychiatrists should be careful to minimize liability when using e-mail. Steps should be taken to decrease the chance of potential harm to the patients. If using e-mail for anything other than administrative purposes, the therapist should document in the patient’s file the reasons for using e-mail as part of the treatment plan—make copies of the e-mail and put it in the patient’s file. The language of the e-mails should be professional and the content appropriate for medical treatment. All e-mail communication should be discussed with the patient during face-to-face sessions.
The patient’s informed consent for the use of e-mails is critical. The patient must be advised about the limits of confidentiality.7 E-mails may never be used in an emergency. In discussing privacy and security issues, the patient should be advised about who sees the e-mails, how often they are checked, and when the patient may expect a reply.
There are a variety of online social networking sites, such as Facebook and LinkedIn; new social network sites are being developed regularly and old ones are becoming obsolete. Online social networking sites present many new challenges to psychiatrists. Does the psychiatrist have a Facebook page or a Facebook profile? The Queen of England has recently joined Facebook, but she does not accept friend requests. On the other hand, some physicians accept friend requests from patients.8 Does it make a difference if this is a former patient?9 How are privacy and confidentiality protected?
Should a psychiatrist ever accept a friend request from a patient? What happens when a patient asks to “friend” the psychiatrist? Context often influences the meaning of boundaries. Even in a small or closed community where people know each other, accepting a patient’s “friend” request can raise problems.
Social networking sites are interactive forums that require careful monitoring in a psychiatrist-patient relationship. Confidentiality is the primary guiding consideration, whether ethical, clinical, or legal. The laws in most states require that confidentiality encompasses the identity of the patient unless the patient waives his right. Accepting a “friend” request from a patient could easily violate this right.
Social networking sites also pose potential problems with HIPAA compliance. Whatever information the patient adds to the communication can be viewed by others. With rare exception, the therapist should not accept a “friend” request from a patient.
While self-disclosure has always been a clinical issue, social networking raises the bar to a new level. Although the therapist may not accept a “friend” request from a patient, he must be careful while social networking. Caution must be used in posting anything on a Facebook profile because it may become available for public viewing. Patients may be friends with the psychiatrists’ colleagues’ friends or others, without the patient’s knowledge, and the psychiatrist’s children may be friends with the patient’s children. Even privacy settings may not protect the therapist. Psychiatrists should educate themselves about privacy options.
Some clinical issues
For all information technology, the privacy and boundary issues that apply are the same as those for social networking. Twitter claims that it cannot guarantee privacy and security.10 Blogging is another concern; the psychiatrist is responsible for all content, even if others are allowed to comment.11
The Wall Street Journal reported that “the average 13- to 17-year-old sends and receives 3,339 texts a month—more than 100 per day. . . . ” 12 If you text, apply the same cautions to texting that you apply to e-mail. The texts should be e-mailed to the psychiatrist’s e-mail account, printed out, and put in the patient’s file.
The AMA House of Delegates, in November 2010, adopted a new ethics policy with regard to professionalism and the use of social media.13 The policy reminds physicians of the ethical responsibilities they should consider when they choose to have an online presence. This includes protecting confidentiality and maintaining appropriate boundaries in the online relationship, just as in any other environment.
The flow of unexpected information about a patient or psychiatrist can have both detrimental and helpful consequences. A patient’s knowledge about the private life of a psychiatrist can affect the therapeutic relationship. The traditional neutrality of the therapist is challenged and the therapeutic framework shifts—boundaries become blurred. The intensity of rapid e-mail exchanges and the affect and pseudo intimacy they can arouse need to be anticipated.
There may be some generational differences in the expectations of privacy and self-disclosure, and how these affect the psychiatrist-patient relationship. Awareness of these issues is important. A policy can help in guiding a psychiatrist’s decisions and in providing a context of safety and comfort for the patient.
Boundaries are needed to protect the therapeutic process and ensure that competent professional services are delivered. Boundaries help prevent harm and exploitation of the patient and protect the psychiatrist from possible legal consequences. As always, care must be exercised to protect confidentiality of all psychiatrist-patient communications.
New technologies pose challenges in the need to maintain boundaries and confidentiality. The same boundaries and ethical standards that existed in the 20th century must be thoughtfully applied with all new and developing technologies of the 21st century. Psychiatrists have a special ethical duty to think through how the use of these technologies affects patients.