Virtual Mentor

Virtual Mentor. June 2012, Volume 14, Number 6: 441-444.

Ethics Case

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Monitoring Blogs: A New Dilemma for Psychiatrists

If a psychiatric patient poses a danger to self or others, it may be advisable to monitor his or her blog after informing the patient.

Commentary by David H. Brendel, MD, PhD

As Dr. Patel, who specializes in treating mood disorders, walks into the waiting room to greet her new patient Jonas, she notices that he is furiously typing away on his laptop. His brow is furrowed in deep concentration.

Jonas was recently hospitalized for mania and psychosis. He was initially brought to the hospital in police custody after claiming to have a bomb in his backpack and assaulting a police officer. At the hospital, he was started on antipsychotic and mood-stabilizing medications and referred to Dr. Patel for outpatient follow-up care.

Even before they settle into Dr. Patel’s office, Jonas is eager to tell Dr. Patel how much he has improved since his hospitalization. “I am a thousand times better already!” exclaims Jonas. “I’ve realized that I’m on a sacred journey of recovery, and so I started a blog to record all the ups and downs. The blog is going to be huge because I already have a ton of followers on Twitter.”

After Jonas leaves, Dr. Patel begins to wonder if she should take a look at Jonas’s blog. On one hand, she thinks it would allow her get to know Jonas better. On the other hand, she wonders whether she would be crossing patient-doctor boundaries by seeking out the blog. Jonas has not asked her to read it. She thinks to herself, There is no telling what may turn up online.

Commentary

Internet technologies in the twenty-first century have provided countless opportunities and potential pitfalls for professional practice in areas as diverse as medicine, law, politics, business, and academia. These technologies have especially serious implications for psychiatry, where emotional complexities, boundary issues, and privacy concerns are of particular concern in the relationship between clinician and patient. In the course of routine clinical practice, psychiatrists nowadays must grapple with questions about whether to exchange e-mails with patients, to participate in social networking sites such as Facebook, and to perform Internet searches in order to learn information about patients. Each of these uses of Internet technologies in psychiatry has received growing attention in the professional literature [1-3]. The case scenario raises the question of whether clinical psychiatrists ought to read and monitor the websites or blogs of some of their patients.

Blogging is a relatively new Internet phenomenon that has gained immense popularity and influence in recent years. On easily accessible blogging platforms such as Tumblr, virtually any person with Internet access can instantly post text, pictures, and video for the public (or a more restricted audience) to view. Among the millions who engage in this activity are psychiatric patients. In just the past few months, several patients in my own practice have mentioned maintaining or reading blogs.

For one of my patients, a high school student, keeping a blog became a major source of distress. Some of what she wrote on her blog apparently led to emotional bullying by classmates at school, and other posts appeared to be maladaptive responses to that bullying. After an episode of self-injurious behavior that appeared to be fueled by this upset, her parents and I convinced her to discontinue blogging in any form. But simply instructing patients whose blogs cause them distress not to blog is an inadequate clinical approach in certain cases. Some patients will continue to blog, even when doing so exacerbates their distress.

Should psychiatrists monitor their patients’ blogs to learn what may be essential clinical information about them? Might it be useful for the psychiatrist to keep an eye on certain blogs and intervene clinically if the patient’s written words raise serious safety concerns, as in the case of a patient blogger with a mood or psychotic disorder who is expressing worrisome suicidal or homicidal tendencies? If the psychiatrist does not monitor a known blog and the patient proceeds to act on a suicidal or homicidal plan posted on the blog, could the psychiatrist later be held liable for inaction? In such cases, failure to hospitalize the patient or to give a “Tarasoff” warning to others might be regarded as negligent clinical care and a serious source of medicolegal risk for the psychiatrist [4].

In the intriguing (and quite plausible) case narrative presented above, the psychiatrist faces this very dilemma. The patient, Jonas, has a severe bipolar mood disorder that necessitated a recent psychiatric hospitalization for assault on a police officer and threats of major violence with a bomb. He most likely remains symptomatic, with grandiose, psychotic thinking still present at the time of the initial outpatient visit to Dr. Patel. At this time, Jonas appears to lack insight into his still fragile (and most likely manic) mental state and he seems overly animated about his blogging activity. Given the recent assault and verbal threats that were part of his acute mania and psychosis, Dr. Patel is right to be concerned about what Jonas is writing on his blog. If Jonas makes violent threats on his blog and Dr. Patel fails to learn about those threats or to act to prevent their execution, a disaster could ensue for Jonas—and possibly for others.

Dr. Patel must decide whether to monitor or “mind” Jonas’s blog in the coming days and weeks, which means Dr. Patel now needs to grapple with a host of ethical issues around privacy and informed consent. Does Dr. Patel have the right to monitor Jonas’s blog without first obtaining his consent to do so? If Dr. Patel begins to monitor his blog without consent, is there an obligation to inform Jonas post hoc about the monitoring and what has been discovered? What information obtained by reading his blog is suitable for entry in Jonas’s medical record? At what point might Dr. Patel involuntarily hospitalize Jonas or give Tarasoff warnings to others based on what Jonas writes on his blog? This case will quickly become incredibly time-consuming, and precarious, for Dr. Patel.

There are no easy, ready-made answers for the ethical dilemmas raised by this case. Professional guidelines, regulatory requirements, and legal precedents do not yet exist for dealing with these situations. In the meantime, individual clinicians must exercise their best judgment on a case-by-case basis. There is no consensus about whether a patient’s blog should be regarded as private (akin to a conventional, handwritten journal) or as public (like anything available on the “information superhighway”). Likewise, there is no consensus as to whether psychiatrists may be medicolegally responsible for knowing about and acting upon material that their patients post on publicly accessible blogs. These issues warrant self-reflection on the part of individual psychiatrists, as well as deliberation (and possibly policy formation) in the broader psychiatric community.

With Internet technology pervading daily life and increasingly affecting the nature of the patient-doctor relationship, psychiatrists cannot avoid engaging these issues. In the course of routine clinical practice, psychiatrists more and more will have to determine whether or not to mind the blogs.

In the case scenario presented above, I would advise Dr. Patel to inform Jonas that monitoring his blog is essential, at least until he is clinically stable and not an imminent safety risk to himself or others. This and ensuing discussions about the blog should be documented in the medical record, and appropriate third parties should be warned if Jonas appears to present a serious and imminent threat. Perhaps Dr. Patel’s informing Jonas about monitoring his blog will lead to fruitful discussions between them that will help to ensure safety and promote Jonas’s best interest.

In general, it may not be realistic to mind patients’ blogs in this manner, in part because it’s so time-consuming and unlikely to be billable clinical work. What’s more, ethical concerns around patient privacy and consent issues will give many psychiatrists pause or inhibit them from seeking out their patients’ blogs.

We may, however, be damned if we do and damned if don’t. The human costs and the medicolegal risks of failure to mind the blogs of potentially violent patients like Jonas could turn out to be unacceptably high. Given this fact, at least in certain special cases, minding the blogs is an essential new role for the twenty-first century psychiatrist.



References

  1. Bovi AM; Council on Ethical and Judicial Affairs of the American Medical Association. Ethical guidelines for use of electronic mail between patients and physicians. Am J Bioeth. 2003;3(3):43-47.
  2. Guseh JS 2nd, Brendel RW, Brendel DH. Medical professionalism in the age of online social networking. J Med Ethics. 2009;35(9):584-586.
  3. Clinton BK, Silverman BC, Brendel DH. Patient-targeted googling: the ethics of searching online for patient information. Harv Rev Psychiatry. 2010;18(2):103-112.
  4. Soulier MF, Maislen A, Beck JC. Status of the psychiatric duty to protect, circa 2006. J Am Acad Psychiatry Law. 2010;38(4):457-473.

David H. Brendel, MD, PhD, practices psychiatry in the Boston area and is the author of Healing Psychiatry: Bridging the Science/Humanism Divide. He has written and lectured widely on the ethics of using Internet technologies in psychiatry practice. More information about Dr. Brendel is available at http://www.drdavidbrendel.com.

The AMA Code of Medical Ethics Opinion on Confidentiality of Patient Disclosure and Circumstances under Which It May Be Breached, June 2012

Duty to Warn and Dissociative Identity Disorder, March 2008

Predicting the Risk of Future Dangerousness, June 2011

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.