Maria’s Blog 10 October 2013
Last night after a couple of bottles of wine and a sneaky joint I decided it was time to face facts. Facts, I said (in a voice so loud I made myself jump like a startled little frog haha!), you cannot be ignored and must be faced. The World Health Organisation needs my assistance and this time I can’t refuse their cries for help. The time has arrived and I have no choice but to follow my destiny and drive through the night (and the ocean) to the Upsala Monitoring Centre in Sweden. “Its your duty” said the little frog sternly. “Indubitably” I replied.
I can’t say I didn’t know this was coming. Something, I said to myself, is coming and that something will come at some point and will then arrive. Oh yes, it was clear, something was definitely coming.
I didn’t need any signs to confirm my instincts, but my tarot card reading last week had turned up the Ten of Pentacles which rhymes with tentacles (tentacles, Octopus, its October, duh!)…no doubt about it, the signs were clearly there. And then there was the fact that only last week in my session with the Doctor, he had said the code words “Good Morning” which I had been informed through a dream were the signal that I was to drop everything and undertake a special mission for WHO (in my dream the mission was for an obese wildebeest but I now understand that was a symbol for ‘a large body’ ie the WHO). “Oh there is no doubt” intoned the wildebeest waving his trunk, “the signs are as clear as day.”
I knew the mission would be perilous. “Gonna be a tough one” I said to myself. I knew I would need the help of a good man. “You’ll need the doctor” I said to myself. And so, I have made the arrangements. The doctor and I will drive the Chitty Chitty Bang Bang car to Sweden where we will star in the WHO’s musical comedy “How Fluoxetine Cured the Blues Brothers” and we will live happily ever after. And the doctor will, throughout our married life, dance the Charleston every Friday night wearing a rhinestone studded mankini as he does in those dreams I have when I’m awake. And his wife will be dead. Lights, camera, action! The way my life is unfolding makes me so damned happy, I have thrown away my antidepressants.
Ok this is not really my blog. I don’t actually have a blog but in the light of articles I have been reading, in which psychiatrists angst over ‘patient-targeted googling’ (PTG ), I’m thinking I need to get myself both a blog and a psychiatrist. This could actually be more fun than running into a psychiatric conference yelling SSRI INDUCED AKATHISIA!!!!!! and watching a thousand psychiatrists explode simultaneously. Well, ok as much fun at least.
The PTG guru seems to be Dr David H. Brendel, a psychiatrist, Certified Executive Coach and Philosophical Counselor who earned his M.D. at Harvard Medical School and his Ph.D. in philosophy at the University of Chicago.
In a paper he co-authored entitled Patient-Targeted Googling: The Ethics of Searching Online for Patient Information Dr Brendel and his colleagues reveal
Through informal surveys of several dozen of our colleagues over the past year, we have learned that most psychiatrists have engaged in PTG. We have (ourselves) searched for patient information, and we have witnessed groups of other physicians Google patients—for example, during formal clinical rounds. We have witnessed and heard reports of PTG across diverse practice settings, including emergency rooms, inpatient units, and long-term outpatient psychotherapy relationships. In the course of such searches, physicians obtain a broad range of personal information about patients: photographs, videos, news stories, criminal records, and details of substance use, intimate relationships, sexual activity, and finances. Content may also include clinically important material such as suicide plans.
In an article he wrote for the American Medical Association Journal of Ethics, “Monitoring Blogs: A New Dilemma for Psychiatrists”, he presents a scenario in which a patient mentions to his psychiatrist that he is blogging. Dr Brendel advises that the patient should be told that “monitoring his blog is essential, at least until he is clinically stable and not an imminent safety risk to himself or others.” He notes, however, that
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 (emphasis added). 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.
Dr Brendel’s advice to his colleagues on the issues of informed consent in relation to PTG are heavily weighted in favour of making decisions based on assumptions about how patients might feel about the practice rather than asking them directly.
If the clinician is certain that the patient would feel hurt or violated if he or she learned that the psychiatrist searched online without consent, then the psychiatrist should seriously consider seeking formal consent prior to searching. If the clinician is uncertain about the patient’s feelings about PTG, then he or she should carefully consider the risk benefit ratio of engaging in PTG without prior informed consent. If there is a high likelihood of clinical benefit from the search and a low likelihood that the patient will feel angry or wronged if he or she later found out about it, then the search may be justifiable even in the absence of prior consent (but…the psychiatrist will have to decide whether to share the results of the search with the patient post hoc). Finally, if a prospective search presents a low likelihood of clinical benefit and a high likelihood of offending or otherwise upsetting the patient, then the clinician ought to seriously consider forgoing the search.
Interestingly, Dr Brendel comments that the absence of professional guidelines in relation to PTG are “possibly…due to potential feelings of shame and guilt associated with admitting to the practice of PTG. 
How fascinating. Why would psychiatrists feel shame and guilt about gathering ‘clinically important information’ supposedly for the patient’s benefit? Could it be that this is an admission that psychiatrists are googling their patients for reasons other than professional practice. That gathering information on their patients’ sex lives, financial situation and criminal history might not be in their patients’ best interests?
Perhaps it is because the ‘composite case studies’ Dr Brendel provides include one where a patient asks for a reduction in his fees as he is getting benefits from his treatment but has limited financial means. The psychiatrist agrees but googles his patients address and the current valuation of the property and finds the patient lives in a multi-million dollar mansion. As the patient is in arrears in his bill, the psychiatrist becomes angry with him and discloses the information he has gained through google. The patient explains that he rents a small basement room in the house since falling on hard times. He pays his bill in full and terminates the relationship with the psychiatrist.  Other case studies in the same article include a psychiatrist going online to find nude pictures taken by the much older boyfriend of his 16 year old patient as part of a risk assessment and another psychiatrist following the profile of her patient and the men she connected with on an online dating site.
In a special issue of the Harvard Review of Psychiatry Dr Brendel makes the point that neither the American Psychiatry Association American Academy of Child and Adolescent Psychiatry, or other psychiatric organizations psychiatrists have provided psychiatrists with guidance on managing the ethical dilemmas association with patient-targeted googling and notes that “The natural consequence of all this confusion is obvious: many clinicians feel paralyzed.” 
So we have psychiatrists who are feeling guilty, ashamed and paralysed by their online stalking of their patients. According to the literature, feeling shame is “consistently correlated with anger arousal, suspiciousness, resentment, irritability, a tendency to blame others for negative events, and indirect (but not direct) expressions of hostility.”
Paralysis of course leads to functional impairment – the hallmark of psychiatric disorder.
On his website, Dr Brendel defines Social Anxiety Disorder as something that is experienced as an overwhelming anxious feeling that someone is watching and judging you and may be generalized or situational. He notes it may interfere with professional functioning and is often comorbid with depression or substance abuse.
Sounds to me like all this PTG is making psychiatrists mentally ill. Poor darlings. MIA bloggers – we must help them as they’ve helped us! After all the googling we do, we know what medical professionals recommend as a cure. Prozac, Paxil, Lexapro, Effexor, we suggest, PTG affected doctors, you work through them until you find one that works for you . . . or until you experience the post-mortem remission of anxiety you gave to many of our loved ones. We like to call this treatment plan “A dose of your own medicine.”
As a further supportive measure, I propose we bloggers give mental health professionals something to get excited about and post entries such as the one at the beginning of this blog. I personally would hate to be responsible for psychiatrists committing non-billable hours to researching me without giving them something to feed their obsession for diagnosis. That wouldn’t be kind and might lead to a Major Depressive Episode.
And by the way, fellow bloggers, Dr Brendel notes that “the psychiatric literature has commented briefly on the use of the Internet as a source of important collateral information.” Given family and friends are key sources of collateral information in mental health it may be that even those of us not under the care of a mental health professional can have our blogs and social networking pages monitored as the friends and family of patients. So don’t be thinking that if you don’t have a psychiatrist you can’t play this game, you absolutely can.
Right now, I’m off to fuel up the amphibious car, wrap the mankini as a wedding gift for my beloved and check the frog and wildebeest have programmed Upsala into the GPS. Until next time…
 David H. Brendel Monitoring Blogs: A New Dilemma for Psychiatrists American Medical Association Journal of Ethics June 2012, Volume 14, Number 6: 441-444.
 Patient-Targeted Googling: The Ethics of Searching Online for Patient Information. Brian K. Clinton, MD, PhD, Benjamin C. Silverman, MD, and David H. Brendel, MD, PhD. Harvard Review of Psychiatry. March/April 2010
 Tristan Gorrindo, MD, and David Brendel, MD, PhD. Internet Technology’s Value in Modern Psychiatry Harv Rev Psychiatry 2010;18:77–79.
 Shamed into anger? The relation of shame and guilt to anger and self-reported aggression. Tangney, June P.; Wagner, Patricia; Fletcher, Carey; Gramzow, Richard. Journal of Personality and Social Psychology, Vol 62(4), Apr 1992, 669-675.