For part 2 of this article, Psychiatry Advisor interviewed Brenda L Curtis, PhD, MSPH, assistant professor of psychology in psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, whose principal research focuses on “big data” generated from social networking sites, technology-based interventions for substance use disorders, and related issues and Internet research ethics.
Psychiatry Advisor: What are some of the potential ethical dilemmas that clinicians face regarding adolescents’ use of technology?
Brenda L Curtis, PhD, MSPH: Privacy is one of the first ethical concerns we have when discussing adolescents and their digital usage. First, many of these platforms are public spaces which, while the individual’s expectation of privacy is limited to the people they believe they are sharing their data with, are actually not private spaces. In addition, once information is posted, it typically is owned by the company to which it was submitted. This can include text, location, app-generated data, and images. When clinicians use these platforms in treatment, this digital data becomes a new form of clinical data that will be integrated into private medical records.
Second, the information obtained from digital platforms, especially user-generated information, may not be accurate. We also are not sure whether using these platforms is healthy and until we are sure we are not prescribing something that does harm, I caution providers about including technology-based applications in treatment. I think we will eventually find out that the answer is “it depends,” but until we are sure the benefits outweigh the risks, we should proceed with caution.
This brings up an important point: control of the “treatment.” When a medication or device is prescribed or used in treatment, we typically have some assurance of its risks and benefits and efficacy. With digital platforms, we do not have this assurance. We are also not sure what else clients are exposed to when using these platforms — for example, digital harassment, inappropriate sexual and drug-promoting content, and online scams such as people pretending to be someone else. Traditional forms of treatment are tested — usually via a clinical trial — and we typically have an idea of the “active ingredient.” This does not occur with digital platforms and apps; the evaluation work has not been done. There could be unintended consequences of using these technologies, so we should be cautious when using them for treatment purposes.
The use of digital information, either to influence or provide treatment, can also have unseen effects. For example, it could encourage unreasonable expectations about what clinicians “should” know, which can undercut efforts to get a patient to take responsibility for their own mental health.
Monitoring of adolescents’ digital lives can also be met with resentment and a feeling of intrusion from the client, even if they gave consent. Monitoring also takes time, whether it is in or out of session.
Psychiatry Advisor: What are the ethical responsibilities of clinicians in this context, and how can they best address these issues?
Dr Curtis: Clinicians must be aware and prepared for how technology can influence treatment and whether it is appropriate for treatment of a given adolescent. For example, monitoring the technology could be seen as a duty, and clinicians could become responsible for the monitoring process. Imagine missing a suicide note because you did not check a patient’s social media page that week.
Clinicians also must be careful about exposing their own lives to patients and be aware that monitoring digital platforms will expose information about family and friends of patients — that they would not typically know and that the client may not want to disclose — to third parties.
Psychiatry Advisor: What are other treatment implications or recommendations for clinicians regarding adolescents and technology?
Dr Curtis: If a clinician is going to use information from various digital sources such as social media or other applications, they should consider the type of practice they have, the nature of the patient population (degree of risk), the type of information they will monitor and how often they will monitor it, and what the patient wants them to have access to. Finally, they need to have a consent process that probably needs to involve the parent or guardian. I would strongly recommend that clinicians create written practices and information sheets for adolescents and their families, which should include a section on what information will be monitored, how it will be used in treatment, and how the data will be protected.
Psychiatry Advisor: What should be the focus of future research regarding the effects of technology use on adolescent mental health?
Dr Curtis: I think researchers can examine the accuracy of information posted online in predicting various mental health outcomes. We can also gain more information about whether clinicians will find this type of information useful and how it might be integrated into treatment. In addition, it would be helpful to evaluate which data sources are the most accurate and how patients respond when they know their digital lives are being monitored.
- Anderson M, Jiang J. Teens, social media & technology 2018. Pew Research Center; May 2018. http://assets.pewresearch.org/wp-content/uploads/sites/14/2018/05/31102617/PI_2018.05.31_TeensTech_FINAL.pdf. Accessed January 2, 2019.
- Sussman N, DeJong SM. Ethical considerations for mental health clinicians working with adolescents in the digital age. Curr Psychiatry Rep. 2018;20(12):113.
- Marchant A, Hawton K, Stewart A, et al. A systematic review of the relationship between internet use, self-harm and suicidal behaviour in young people: The good, the bad and the unknown. PLoS One. 2017;12(8):e0181722.
- Lenhart A, Smith A, Anderson M, Duggan M, Perrin A. Teens, technology and friendships. Pew Research Center. 2015. www.pewresearch.org/wp-content/uploads/sites/9/2015/08/Teens-and-Friendships-FINAL2.pdf. Accessed January 2, 2019.
- Jiang, J. How teens and parents navigate screen time and device distractions. Pew Research Center; August 2018. http://assets.pewresearch.org/wp-content/uploads/sites/14/2018/08/21153052/PI_2018.08.22_teens-screentime_FINAL.pdf. Accessed January 2, 2019.