Should Your Therapist Read Your Twitter?

In January, researchers at Sigmund Freud University in Austria published a study asking therapists, psychologists, and psychiatrists if they looked up information about their patients online.

The results were mixed. Nearly 40 percent said they had done some kind of search, but of the remainder that didn't, many questioned whether it was ever appropriate to look up a client. Some doubted the basic reliability of the source—"lot of trash on the internet," reads one response—but most saw it as a serious violation of trust that could potentially damage the therapeutic relationship.

"I suspect this comes up a lot for people in practice," said Dr Mayura Deshpande, chair of the Professional Practice and Ethics Committee at the UK's Royal College of Psychiatrists, in a phone call. She noted that while there aren't any regulations stopping a psychiatrist from looking up their patients, she personally thinks it's an invasion of privacy.

What makes the issue so difficult, according to the limited studies and commentary available, has to do with the nature of mental health services: a professional relationship that relies extensively on personal information and trust.

"We do hear very personal details, about people's relationships, childhood, families, that you just wouldn't need to know if they'd broken their leg," said Dr Alice Ashby, a consultant psychiatrist and the lead author of a recent commentary for the British Journal of Psychiatry Bulletin on the ethics of searching or monitoring patients online.

"I don't like the idea, ethically, of searching for information without consent; it feels like a boundary violation," she added. "Having said that, we shouldn't let that shut down the conversation about it."

Mental health professionals are coming to the conversation pretty late. Debates about whether your employer or teacher should be able to search your information or monitor your social media presence have been going on for more than a decade. The only other study looking at psychiatrists and therapists was a group at Harvard who did an informal survey of "several dozen" of their colleagues and found that "most psychiatrists" had searched for information—they recommended further discussion and study. That was back in 2010, a lifetime in internet terms, and a period during which, presumably, your therapist could have been reading your Twitter.

But should they? Some argue that the internet is just another resource to gather personal history from. But others think that anything that doesn't come directly from the therapist-patient relationship isn't useful anyway, and respecting a patient's boundaries is the most important thing—"patients need to be in control of what they say," according to one of the respondents in the Austrian study. Everyone, though, seems to agree that trust is both vital and delicate, and that the idea that a person is being inspected or surveilled, even with their knowledge, could seriously harm that.

Ashby and her co-authors, for instance, think that information found on the internet could be helpful as a form of "collateral history." They imagine that a potentially delusional patient's claims could be checked against an internet record, or that "dangerous lifestyle choices" such as drugs or excessive drinking could be monitored through social media. But while that information could be useful to their work, possibly even informing diagnoses, they caution that the patient must be informed.

"We felt strongly that if you were searching people at all it should be where they have capacity to consent and it would be with their consent," said Ashby.

The authors also worry, however, that even with consent that sort of monitoring could be seen as paternalistic, especially to people who may be used to "the validity of what they are saying being doubted." There's an issue of power, too. Even if a patient consents to being searched or monitored, they may feel coerced. And afterward, uncomfortably aware that whatever they post online may be seen by their psychiatrist.

Dr Deshpande, who admits she's a bit old school, would argue that the easiest way to avoid all these issues is not to consult the internet in the first place. "Our job is not to build up a sort of dossier on the person, but actually work with the information that a person gives you," she said. She's especially wary of using internet or social media searches to confirm someone's claims or fact check.

"Someone who comes to see a psychiatrist brings a certain amount of information or reveals a certain amount of information; there is something important about taking that and working with it," she said. "Personal information that isn't intended for the clinician is very hard to justify."

That idea of intent is important, too. One of the respondents in the Austrian study claimed that "anyone who provides their personal data on the internet implicitly gives permission for this to be seen by others."

But that's not necessarily how it works. Samaritans, a UK-based mental health charity, debuted an app called Radar in 2014. Radar monitored users' Twitter feeds and alerted them when anyone they followed used key terms suggesting they might be suicidal. The idea was to use both the scale and intimacy of social media to connect with vulnerable people; in practice everyone thought it was creepy. Tweets may be in the public domain, but nobody wanted a public suicide watch. The app was suspended a week after it launched.

"People do have an expectation of privacy in spaces we think of as public," said Paul Bernal, an internet privacy researcher and lecturer in law at the University of East Anglia. He pointed out that while expectations are different than legal rights, they're still important.

"With mental health, expectations are in some ways even more important—you want to be able to trust that the people dealing with you have at least some understanding of what your ethical expectations and privacy concerns may be," he said.

In other words, if mental health professionals aren't clear about those expectations, they risk violating boundaries they may not even be aware of. The studies that exist all call for more research into how often psychiatrists and therapists monitor their patients, and why, but it might be even more useful for them to find out what patients think about about internet privacy, and how they feel about having their online presence monitored. Ashby said she got approval to do a study like that two years ago, but her job changed before she could begin.

She also thinks that being more aware of how patients use the internet and social media would be good for her profession in general. "It's a bigger question than 'Do we search for people on the internet?'" she said. "I think it's important to ask people about their social interactions on the internet as much as we would ask about their relationships in real life. I don't think we necessarily teach that."

She's right that there isn't much guidance available for mental health professionals on internet use, ethical or otherwise. There are currently no specific rules covering internet or social media searches for patients from any of the major medical bodies for psychiatrists in the US or UK. Guidance for therapists, who are generally less closely regulated, vary by professional body—the American Psychological Association, for example, doesn't have specific ethical guidance for the internet yet, but has addressed the issue in its publications and recommends talking to a client before before looking at anything they may have posted online.

That may soon change. The authors of the British Journal of Psychiatry paper claim there is an "urgent need for this topic to be addressed," and Dr Deshpande said that she has noticed people talking about it—and she's going to bring it up at the next ethics committee meeting.

I asked Christiane Eichenberg, the lead author of the Austrian study, why it had taken so long to address the issue of internet privacy. "It's a phenomenon that´s common for any study that focuses on your own profession—there's a resistance to shine a light on negative aspects," she said.

But, like any problem brought into therapy, it's not going to get fixed if it's not talked about.