Googling Patients: Should Psychiatrists Research Cases Online?

When Sigmund Freud's upscale patients trundled up to his parlor at Bergstrasse 19 in Vienna, one thing they didn't need to worry about was whether their shrink had checked out their Facebook page, read their latest blog rant, or Google-mapped their house and looked up its value on Zillow.

But apparently, you do. In a world where physician Googling has become the norm, a surprising, even shocking number of psychiatrists are Googling their patients.
Our digital lives are colliding with the doctor/patient relationship – and carrying risky consequences. That is one of the conclusions of a freshly published paper in the Harvard Psychiatric Review, titled "Patient-Target Googling: The Ethics of Searching Online for Patient Information." The study, written by Drs. Brian K. Clinton, Benjamin C. Silverman and David H. Brendel, is both an exercise in medical whistle-blowing and an effort to offer mental health professionals a set of new parameters for the digital world.

In one sense, that's hardly surprising. The Internet is massively autobiographical, and turning to a search engine when we meet someone new has become reflexive for many of us. Nonetheless, the Harvard Psychiatric Review is the first major academic paper on the subject (which is surprising in itself), and it's eye-opening. The idea of therapists researching their patients online makes sense when you think about it. Only we don't. Dale Atkins, a noted psychologist and author told me, "I hadn't really focused on it or even thought about it until you brought it up."

How common is the practice? Brian Clinton told Politics Daily that while there are no statistics, he wouldn't be surprised - given how easy, effective and tempting searching has become - if more than 50 percent of therapists have click-click-clicked their way into a patient's online life. And in the majority of cases, the patient is likely to be unaware they've been pursued online. That's a problem for Dr. Clinton, a potential breach of the sacred bond of trust. Dale Atkins was equally firm. "Googling a patient would be a "violation of the contract between us," she said. "Therapy is about privacy, confidentiality and boundaries."

The Internet has changed everything else, and is in the process of transforming medicine. (There is a huge amount of money -- some $20 billion -- in the stimulus package for digitizing patient records.) If you're a believer in the general rule of thumb that more information is better, your gut reaction might be that giving therapists access to the full canvas of patient's life is a great idea. Certainly many therapists, whatever their view of the Information Revolution, have been frustrated at being locked in an office with their patient, with no source of information about their lives, their temperaments, their interactions outside of the psychic sanctuary.

But that's a naïve and untrained view, says Atkins. "Who my patients are in the world doesn't define the difficulties they have in their own mind when they are in my office," she told Politics Daily. "They may have a thousand friends and feel like an imposter." Herbert Rappaport, a psychologist in private practice is also comfortable with the picture of a patient that a "creative clinician can construct in a therapeutic environment." Moreover, the private world is what matters, because "The bias of the analytic model is to get into the head of the person, to be more concerned with psychic than physical reality."

All of which makes Googling a patient fraught with questions and consequences. Should a therapist do it without a patient's knowledge, or only with informed consent? And what happens, for example, if a patient who is sensitive to rejection asks their therapist to read their blog, and is refused? Or doesn't have time to read the last one? Does it amplify the risks of transference and counter-transference? What are the insurance issues, should the clinician stumble upon a risky behavior? Should any online investigation happen alone, or with the patient? (All the experts I interviewed felt strongly that it should only happen in session, so the patient can to control the exposure, and the psychiatrist or psychologist is more likely to be restrained from "one more click" temptation.)

And then there's the issue of the manner in which patient choose to reveal themselves in a therapeutic setting, and the complementary art of interpretation. Issues, anxieties, themes and leitmotifs don't roll out with sequential predictability; the very unfolding of a narrative could be as or more important than its components. Googling creates unhealthy data acceleration. "Some information needs to emerge in its own time" is the way Brian Clinton put it in an interview. And keep in mind that those who provide mental health services have no training whatsoever about how to evaluate online patient information and apply it to their clinical work.

Of course there are instances of potential violence – self-inflicted, or otherwise. But even those aren't always clear-cut. The recent Harvard paper argues that an entirely new decision-making apparatus is called for. The profession doesn't have one now, and a consensus isn't coming any time soon. When asked about the feedback to the paper, Clinton replied that it was all over the map. "Some physicians said you should never do it," he said. "Others said it should be done all that time, that they have every right to Google a patient." But Clinton was firm in his own professional standard: "I don't believe that myself."

One fascinating subtext of the Google reflex is the motivations of the therapist themselves. Shrinks are trained to take themselves and their own baggage of neuroses out of the doctor/patient equation. It's not always easy to do that; it requires vigilance, particularly when seduced by the easy allure of the Internet. Brian Clinton pointed out that psychiatrists are drawn to the discipline because they are compelled in people and their stories: "For all therapists, there is an intense curiosity to see whether what they see in the therapy room matches the real world."

It's one that must be resisted. As the paper dryly notes:

"When they consider learning about their patients via PTG, [psychiatrists] must strive to acknowledge honestly to themselves the full range of their motivations, which may include straightforward curiosity and voyeuristic interest."

One question arises that is not dealt with in the Clinton-Silverman-Brendel paper: Is Googling patients a bit of a pay-back by doctors who are Googled constantly, and for whom the Internet has created a flood of patients who think they're experts, along with a torrent of anonymous and negative website comments from unhappy customers. When that question was put to Dale Atkins, she laughed and said that it's definitely possible. "You know more about me than I am comfortable about, so I want to know everything about you."
Googling a patient is also a form of defensive medicine; is that patient in my waiting room a serial litigator?

The Harvard paper provides some chilling examples of possible "ethical dilemmas," including vignettes of a female therapist who spent time checking out the online profiles of her female patient's romantic prospects, and a psychiatric resident who might have gone too far in seeking out provocative photos of a 16-year-old emergency room patient. Then there's the therapist who went to Google maps and discovered that a patient who was pleading poverty lived in a mansion. (Well, actually, he rented a room there, which wrecked the therapy after the doctor wrongly confronted him).

In their paper Clinton and his co-authors offer a set of parameters for mental health professionals, urging them to ask themselves six probing questions, including why they want to make a particular search, would it advance or jeopardize the therapy, how do they monitor their own motivations, and should the results be shared.

How should the millions of patients in therapy react to all this? At the very least, every patient should ask their mental health provider for the details of their Google policies. Technology plays a delicate role in therapy. Ultimately, as Brian Clinton notes, psychotherapy is a relationship, and "healing is dependent on two human beings sitting together, putting feelings into words...with a goal of liberating the patient from suffering."

In other words, availability and utility are not the same. Just because doctors can seek and find doesn't mean they automatically should. Just because patients are comfortable living online doesn't mean those digital personas should be brought into the doctor's office. We'd like to believe that the more our therapist knows about us the better off we will be. But in a follow-up email, Dr. Clinton takes a stand against the unmitigated benefits of disclosure. "Many psychoanalysts today, he wrote, "would argue that omniscience on the part of the therapist is a misdirected fantasy, and to know more and more about a patient, by whatever means possible, is not inherently therapeutic."

Yes, we live in a more-is-better, tell-all, show-all, know-all world. But not all the time. And not everywhere. The digital equivalent of "sometimes a cigar is just a cigar" might be that over-interpretation's risks include over-Googling. You can search for the truth of a patient's inner life without searching.