David J. Hellerstein, M.D.: Goodbye Blank Screen.

This is the print preview: Back to normal view »

“So I checked you out on the Web,” says M., a patient I was seeing for a psychiatric consultation. “That’s why I decided to see you.”

A few moments on Google had shown M. my research clinic, my literary writing, and “other stuff.” Other stuff? I could only imagine what she might have seen. I was relieved when M. moved on to her immediate concerns. But this brief interchange three years ago got me to thinking. Were other patients also checking me out on the Web? What were they finding? And should I care?

Traditionally, psychiatrists and other therapists work most comfortably in relative anonymity. From the earliest days of training, we learned the virtues of reticence. Should a patient ask, “Are you married?” or “Where do you live?” every trainee knew the best response was silence — or perhaps the retort, “What are your thoughts about that?” For many decades, Freud’s followers promulgated the idea that a therapist should be a blank screen. The watchword was “abstinence” — personal, not substance- or sex-related. The goal was to avoid “contaminating the transference,” the intense feelings that were supposed to develop in the absence of actual facts, and which were believed essential to the progress of therapy. Often, even years into treatment, a patient would know little about her therapist’s actual personal life.

For a therapist practicing in 21st century America, abstinence seems wonderfully quaint. For one thing, psychoanalysis is no longer the therapeutic ideal. Compared to analysts, cognitive therapists are less concerned with “transference” or hiding information about a therapist’s life. Plus, in the post-Prozac age, medications often supersede talk therapy. If a psychiatrist spends most of her time writing prescriptions, attempting to normalize aberrant brain circuits, her personal disclosures become fairly irrelevant — not unlike one’s internist chatting about his golf game.

Even within psychoanalysis, things have changed. In place of the traditionally-distant therapist, modern analysts have developed a theory of “intersubjectivity,” arguing that:

“… once the psychoanalytic situation is recognized as an intersubjective system of reciprocal mutual influence, the concept of neutrality is revealed to be an illusion. Hence, interpretations are always suggestions, transference is always contaminated, and analysts are never objective.”

And there may be more than one transference, argues psychoanalyst Glen Gabbard: “Data from cognitive neuroscience corroborate the notion that there are multiple transferences. Each reflects different representations and different activations of neural networks.” A therapist’s appearance or office decor may trigger a particular network of associations, which are different than associations triggered by a different therapist or a different office. Anonymity becomes cognitively impossible, so “the image of the ‘blank screen’ analyst is no longer viable.”

But more than anything else, therapists are being blasted out of comfortable anonymity by the Web. A few clicks into Google can uncover more about your prospective therapist than an old-fashioned gumshoe working for weeks. Not only dry professional credentials, but juicy stuff — political contributions, divorce records, lawsuits, etc. Spokeo and other web consolidators have eliminated hard labor from cyber-snooping. What took months to years of fantasizing to construct — a fabrication that was often wildly askance from the “truth” — now takes but a few clicks.

And then, of course, there’s Facebook, where it’s not so much a question of photos you’ve posted but where others have tagged you, and worse, reposted content beyond your control. Crazy nights in Cancun, the air guitar at a local pub, your plié in a tight leotard… how long will those pictures haunt you? When I mention this to young doctors I supervise, they queasily hasten to inform me that they have decided to unFacebook their lives.

If only! — as my kids would say. If only tweaking Facebook settings could return us to comfortable anonymity!

And thus, M. is only an exception in her candidness about searching: My guess is that many, if not most, new patients Google their therapists or doctors before ever entering the consulting room. One young doctor, for instance, told me that she had Googled her analyst “like crazy” before seeing him — but only gradually admitted it months later. A psychologist tells me how one patient asked out of the blue, “Are you going on maternity leave soon?” Finding her wedding pics had required going several pages into Google Search.

Since the blank screen is dead, what will take its place?

We older therapists, digital immigrants — if not digital refugees — may cling to the delusion we can hide ourselves from the Web. For the younger generation, digital natives all, there will be no way to erase their footprints. Instead of default anonymity, they assume universal nakedness. They quickly realize (often to their dismay) that new patients can know everything. (For that matter, since therapists also Google, patients must adjust to a world in which they lose the luxury of gradually revealing their own secrets!)

Can therapy survive a world of TMI? How can fantasies about your therapist possibly sprout when you already know their dogs’ names, not to mention their kids? Perhaps the best model is an old-fashioned one: a doctor practicing in a small town. He does a colonoscopy on the man who bags his groceries; she eats brunch beside the couple she sees for marital therapy. In small towns everyone knows everything about everyone.

If it’s possible to be a good doctor in such settings — and an effective therapist, since psychiatrists also live in small towns — perhaps it will also be in the era of Spokeo. I know I’ve already adjusted my assumptions as a therapist, incorporating intersubjectivity and multiple transferences into my theoretical approach. I’ve become more comfortable being a “real person” to my patients. And on a practical level, only a few years after my patient M. admitted what she had found about me on the Web, I’m now ready to be shocked when patients claim that they haven’t Googled me.