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Letters to the Editor   |    
Locating Clinical Boundaries in the World Wide Web
HENRY WHITE
Am J Psychiatry 2009;166:620-621. doi:10.1176/appi.ajp.2009.08101464

To The Editor: Internet search engines and social networking sites, such as Google and MySpace, have radically redefined the nature of personal privacy (1). The ethical and clinical implications of this new technology for the doctor-patient relationship have yet to be explored. The present case report highlights this challenge.

A 7-year-old boy began treatment for posttraumatic stress disorder after moving to a new state to live with his grandfather. The grandfather told the psychotherapist that the child’s parents had been killed in a plane crash but was consistently unwilling to elaborate on the details of the event. When the child’s symptoms continued to intensify, despite weeks of treatment, the clinician sought to learn more about the traumatic event via an Internet search, using the patient’s name and prior residence as keywords. The search results included a newspaper article describing the murder of the child’s parents by a relative. When the clinician revealed to the grandfather that she had obtained this information, he terminated the child’s treatment and stated that he had hoped to give the boy a “fresh start” by not revealing the details of the parents’ death, and he felt that his family’s privacy had been seriously violated.

Using search technology, clinicians can easily obtain information about patients without their prior consent, but such investigations may have a profound effect on treatment. An undisclosed search can disrupt the working alliance and undermine the therapeutic neutrality of the psychotherapist, who will be constrained by the burden of holding a secret. Revealing the search will surely affect the transference, and the patient may well experience it as a boundary crossing or violation (2).

In an instance in which a clinician does not disclose an Internet search to a patient, a number of issues may be present. For example, it is difficult to respond neutrally and naturally to a patient when he or she reveals a confidence with which one is already familiar or when confronted with discrepancies between the person in the office versus the persona on the Web.

There are situations in which a search without consent may be completely appropriate. For example, in the course of evaluating a noncommunicative patient in an emergency setting, a Web search might be an invaluable tool for finding relatives or other informants. One therapist reported locating a missing teenager by viewing the teenager’s MySpace page (Nancy Baldwin, personal communication, October 1, 2008).

It is appropriate for physicians to be curious about their patients’ lives. However, under most circumstances, I believe that we should refrain from satisfying this curiosity by searching for information without our patients’ knowledge or consent. In contrast, a consensual inquiry into how patients present themselves on the Web, on social networking sites for example, can be very productive.

Determining the therapeutic geography of cyberspace is an urgent task. To the best of my knowledge, there have been neither studies documenting current practice nor guidelines promulgated by professional organizations. Mental health clinicians and their patients will learn about each other through Web searches. The challenge is not to ignore this new terrain but rather to develop an understanding of how to negotiate it ethically and therapeutically.

1.Dyson E: Reflections on privacy, 2.0. Sci Am 2008; 299:50–55
 
2.Gutheil TG, Brodsky A: Preventing Boundary Violations in Clinical Practice. New York, Guilford Press, 2008
 
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References

+The author reports no competing interests.

+This letter (doi: 10.1176/appi.ajp.2009.08101464) was accepted for publication in January 2009.

+Reprints are not available; however, Letters to the Editor can be downloaded at http://ajp.psychiatryonline.org.

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References

1.Dyson E: Reflections on privacy, 2.0. Sci Am 2008; 299:50–55
 
2.Gutheil TG, Brodsky A: Preventing Boundary Violations in Clinical Practice. New York, Guilford Press, 2008
 
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