Future Tense

How Does That Make You Tweet?

How therapists can—and should—use social media to monitor clients.

Twitter didn’t cause Amanda Bynes to spiral, but the thousands of responses to her disorganized statements certainly don’t help.

Photo illustration by Lisa Larson-Walker. Photo by Reuters.

Paparazzi aren’t the only ones documenting former child star Amanda Bynes’ mental health problems. Gawkers have also kept tabs on her via her Twitter account. Bynes’ most recent hospitalization occurred when she tweeted accusations that her father sexually abused her, then blamed the false statement on the “microchip” in her brain. Then a few weeks ago, after she was caught sleeping on a couch in a California shopping mall, the star again took to Twitter to share that she had been diagnosed “bipolar and manic depressive,” which a psychiatrist will tell you are the same thing.

While it’s reassuring to see Bynes report that she’s seeing a therapist and a psychiatrist, it’s unnerving to see 3.6 million Twitter followers take a front-row seat to someone’s descent into mental illness. But I’m not condemning them, because I’ve been following her, too. Engrossed by Bynes’ psychiatric odyssey, I was surprised by how quickly I joined the diagnostic guessing game for a person I had never even met. And I’m a therapist!

Social media psychology might be the new armchair psychology, but there may be more to the phenomenon than just tabloid fodder. Researchers have begun to examine social media data as a gold mine for legitimate mental health assessments.

In the world of mental health, we’re not far from the day when scrolling through your Twitter feed might be a practitioner’s last step before pulling out the prescription pad. Despite their advancements, psychiatry and psychotherapy remain fields that rely heavily on self-reporting. What we report is subject to recall bias, and this is the snag every clinician must maneuver to gain a clear picture of our symptoms.

However, social media never forgets. Look back through your Facebook wall or your Twitter feed, and you might see some informative patterns. While monitoring social media without consent is obviously unethical, a patient who’s willing to examine her social media presence might find an ally in the data, says Dr. Jan Kalbitzer, a physician at Charité-University Medicine Berlin.

“Say a bipolar patient is prone to depressive and manic episodes,” says Kalbitzer. “A clinician and the patient can use social media to predict a new episode. If social interactions decrease, this could be a sign of a beginning depressive episode well before other symptoms are present.”

I’ve never asked a client to open a smartphone app or print out a Facebook page. Social media is a sacred space for the anxious brain, and I’m not sure I’d want to enter, even if invited. We teach counseling students never to search for their clients online, and monitoring social media, even with permission, collides too many worlds. Perhaps its my hesitation at what my own therapist would think if she perused my Twitter feed, the manic rambling during an episode of The Good Wife or the narcissistic whining about writer’s block.

Curiosity, however, is an antidote to anxiety. Therapists ask clients to record their moods, thoughts, sleep patterns, and even information like blood sugar and cortisol levels. So why shouldn’t social media be on the list? When a person feels curious about their behaviors rather than defeated by them, the space for change opens up.

While content itself can be misleading, examining posting patterns also could provide valuable information about the health of a therapy client. Say someone’s suddenly extremely active or he becomes more aggressive in his remarks to other people. These changes could be interpreted as symptoms leading up to a crisis, and early detection could save the patient from another trip to the hospital or damage to his work or home life.

Unlike many symptoms that go undetected, our behaviors on social media also have a constant audience. Scrolling past a stranger’s bizarre post might not leave us awake at night, but when it’s someone we know, the bystander effect is the enemy. Clinicians recommend that you should respond the same way you would if a person were exhibiting the behavior in front of you. So if you’d be concerned if your bipolar friend showed up naked at your front door, then seeing them sans clothes in a Tumblr post should warrant the same intervention.

While your shrink might not be asking about your Pinterest habits any time soon, researchers have begun to construct learning models that analyze the feeds of thousands and even millions of users to try to make larger inferences about mental health. These algorithms aren’t in danger of replacing clinicians, but it’s likely that one day I will have a client walk in and tell me that Facebook recommended he see someone.

In fact, researchers at Georgia Tech recently found that they were able to predict post-partum depression in mothers from their pre-partum Facebook feeds. The algorithm searches for words, phrases, and emoticons that indicate positive or negative emotions. Given the chameleon nature of the disease, however, researchers face the challenge of incorporating these shades of blue into the way they collect and interpret data.

Engaging social media in research also requires examining its potential to aggravate symptoms. Twitter didn’t cause Amanda Bynes to spiral, but the thousands of responses to her disorganized statements certainly don’t help. A depressed, less-famous Instagram user could scroll past pictures of her smiling friends and experience increased feelings of isolation. And while you might grimace at the eerie accuracy of the marketing ads on your Facebook account, this scrutiny could be the final straw when someone is predisposed to psychosis and paranoia.

Kalbitzer and other clinicians have observed that patients sometimes incorporate spam tweets into their paranoid delusions, causing or aggravating what they refer to as “Twitter psychosis.” In one case study, they reported a suicidal patient who used the platform for hours a day and believed a famous actor was trying to communicate with her through cryptic symbols in his tweets.

For all its hazards, social media does provide instant and anonymous opportunities for users to express themselves and their struggles with mental illness. But as supportive communities carve out this space, the platforms must consider their responsibility in preventing harm and encouraging good mental health.

The truth is that there is no easy response because there’s no easy solution. To battle the promotion of self-harm or anorexia, Instagram has outright banned popular hashtags like #thinspiration. Other platforms like Tumblr choose not to remove content but to program features that direct users toward positive interventions. For example, searching for the word “depression” will lead you to a link for 7cupsoftea.com, a site that provides “trained active listeners” and ensures confidentiality.

Other programs depend on live users to be the safety net.  The Samaritans Radar app scans your Twitter feed for suicidal ideation and notifies you when someone needs help. Critics have debated whether the app is an invasion of privacy and if users not trained in crisis intervention should assume responsibility for a potential stranger’s health.

Of course there are limitations to what social media can tell us. People act differently on the Internet than they do in real life. The author of many a raging Internet comment might be silent during a heated dinner conversation, and the life of the party might have zero interest in sending a Snapchat. Poor judgment on social media also doesn’t necessarily equal poor judgment in real life, and the chaotic atmosphere of the Web makes it difficult to fit any observations into a diagnostic box.

While some might see the anonymity of social media affording a more authentic portrayal of self, it’s difficult to draw inferences without any face-to-face follow-up. Behind the curtain of the Internet, a cry for help could be a cry for attention, a joke, or a form of satire. We all know that a teenager tweeting, “Justin Bieber is so perfect that I want to die,” probably isn’t contemplating suicide, but other snippets of emotion and information can be difficult for even a trained eye to unravel.

For the average user, however, these nuances shouldn’t keep you from asking someone if they need help. “When it comes to your personal relationships, if someone indicates crisis and distress, you should view it as crisis and distress,” advises Dr. Dror Ben-Zeev, a clinical psychologist and faculty member at Dartmouth’s School of Medicine. “And if that’s just not the case, well then I’m happy to be wrong. ”

This article is part of Future Tense, a collaboration among Arizona State University, New America, and Slate. Future Tense explores the ways emerging technologies affect society, policy, and culture. To read more, visit the Future Tense blog and the Future Tense home page. You can also follow us on Twitter.