Recalibrating Therapy for Our Wired World
By RICHARD A. FRIEDMAN, M.D.
Published: October 8, 2012
via Recalibrating Therapy for a Wired World – The Digital Doctor – NYTimes.com.
Speed, instant gratification, accessibility — these are a few of the appealing hallmarks of digital technology. It’s no coincidence that we love our smart wireless devices: Humans are a notoriously impatient species, born with a preference for immediate rewards.
But the virtues of the digital age are not always aligned with those of psychotherapy. It takes time to change behavior and alleviate emotional pain, and for many patients constant access is more harmful than helpful. These days, as never before, therapists are struggling to recalibrate their approach to patients living in a wired world.
For some, the new technology is clearly a boon. Let’s say you have the common anxiety disorder social phobia. You avoid speaking up in class or at work, fearful you’ll embarrass yourself, and the prospect of going to a party inspires dread. You will do anything to avoid social interactions.
You see a therapist who sensibly recommends cognitive-behavioral therapy, which will challenge your dysfunctional thoughts about how people see you and as a result lower your social anxiety. You find that this treatment involves a fair amount of homework: You typically have to keep a written log of your thoughts and feelings to examine them. And since you see your therapist weekly, most of the work is done solo.
As it turns out, there is a smartphone app that will prompt you at various times during the day to record these social interactions and your emotional response to them. You can take the record to your therapist, and you are off and running.
Struggling with major depression? Digital technology may soon have something for you, too. Depressed patients are characteristically lacking in motivation and pleasure; an app easily could lead patients through the day with chores and activities, like having a therapist in one’s pocket. Not just that, but the app might ask you to rate depressive symptoms like sleep, energy, appetite, sex drive and concentration in real time, so that when you next visit your psychiatrist, you can present a more accurate picture of your clinical status without having to worry about your recall.
When it comes to collecting and organizing data, software is hard to beat. But information has a tendency to spread, especially digital information. To wit, electronic medical data containing sensitive personal information can be released, either accidentally or deliberately, and disseminated. Anyone who has followed the hacking of supposedly secure and encrypted financial databases knows this is not a remote possibility.
More worrisome to therapists, perhaps, is that technology also enables access: These days patients reach out via text, e-mail, Facebook, Twitter. For some of them, the easy connectivity that technology makes possible is a decidedly bad idea.
Take a patient who has a fundamental problem in maintaining intimate relationships and who can’t tolerate being alone without feeling bored or anxious — in other words, a patient with typical features of borderline personality disorder. Not surprisingly, such a patient would love instant access to a therapist whenever an uncomfortable feeling arises.
In this case, connectivity would interfere with the central goal of any reasonable treatment, namely acquiring the skills to manage painful feelings by oneself and the ability to tolerate some degree of disappointment. Access-on-demand would mitigate efforts to develop patience and frustration tolerance, and might encourage a sense of entitlement and an illusory notion of power and control.
But perhaps the more difficult challenge is this: By removing barriers to access, digital technology can make therapists more real and knowable to their patients. This cuts both ways.
Recently, a patient I had treated for depression was struggling with the approaching death of his beloved dog. Just divorced, he was dreading another loss. One night while surfing the Internet, he came across a piece I wrote years ago about the death of my own dog.
“So you understand what it’s like,” he said during one of our sessions. This discovery made him feel understood and comforted.
Sometimes, though, digital technology can undermine the clinical rationale for a therapist to maintain distance.
For example, in insight-oriented psychotherapy, which focuses on unconscious processes at the root of personal conflicts, the patient essentially uses his relationship with the therapist to understand how he structures relationships with people in general. The therapist must be free to “become” many different important people in the patient’s life; the more the patient knows of the therapist’s real life, the likelier it is that the treatment will be confounded.
Imagine how you might feel if you had a philandering parent and were having trouble in your own relationships, and you discovered that your own therapist was married and having an affair. It would be hard to believe this would not affect your relationship with your therapist.
Many patients don’t want to know how their therapists feel or the details of their personal lives, and for a good reason: It can undermine the perceived authority of the therapist, making patients feel less secure. And it can inhibit patients from being open for fear of hurting or upsetting their therapists.
I wonder if it’s even possible for therapists to remain anonymous in the age of the Internet, where we can all be found in the electronic cloud. A Google search might not reveal a therapist’s deep, dark secrets, but even basic information begins to alter the relationship.
Last summer, a patient learned that I was swimming in a benefit race in Cape Cod because I’d written something about it that was available online.
“Be careful, Dr. Friedman,” he said with a smile on the way out of my office. “I heard there were sharks out there.” Beneath the humor was anxiety — or perhaps something darker.
Digital technology has the potential to either enhance or confound therapy, but much depends on the patient and the condition being treated. Some patients will find that the glowing screen only feeds their psychopathology. Others will find digital technology a boon to self-esteem and assertiveness. We are only beginning to figure out which patients are which.
Googling Your Therapist
Posted: 07/25/2012 5:13 pm
You’re starting therapy. Maybe this is your first time. Maybe you are a veteran. Either way, you’re probably curious about this person you’re going to meet. Let’s imagine a she. Where did she go to school? Is she married? Does she have children? This is just the surface. Depending on your history, you have other questions that matter to you: Is she rich, gay, successful? Has she had personal experience with divorce, sexual abuse, depression? You start Googling.
If you’ve already done this, don’t worry — you are in good company. As Ofer Zur, a psychologist who has written extensively on the ethics of Internet use for psychotherapists, reports, “… modern day consumers routinely Google potential healers, products and services as part of their due diligence in shopping…” with information available on the Web about therapists, spanning material posted by practitioners on professional websites to material outside a therapist’s control, such as records of political contributions, photos from charity events, and parents’ obituary notices.
A generational divide exists, Zur notes, between therapists in training — by and large, “digital natives” — and their supervisors and teachers — by and large, “digital immigrants” — regarding Internet use. Setting off alarm bells for the digital immigrant generation of therapists, Google searches are becoming a two-way street: In one 2010 study, 27 percent of student therapists reported having used the Internet to search for information about their clients.
None of this will be resolved before your first meeting with your therapist. If, however, you have not already succumbed to the Google reflex, pause… and reflect. Reflection, after all, is one of the primary purposes of your treatment, a muscle you will be developing. Ask yourself if sating your curiosity is in your best interest. You absolutely should know whether your prospective therapist is well-trained, respected in the community, has expertise relevant to why you are seeking treatment. Ideally, you would have been referred by someone qualified to advise you on these questions: another therapist, your internist, perhaps a smart friend who knows someone treated by the person you are considering. What you don’t need is the Internet fishing trip that yields the price of your prospective therapist’s home or her marriage announcement.
Why might you want to experience your therapist fresh — not with bits and pieces from an Internet search on your mind? After all, the idea of the therapist as a “blank screen” was hardly applicable to Freud’s own work when he analyzed his daughter and some of his closest colleagues. You might want to experience your therapist fresh — unimpeded by the Google bounty — for the same reason Cindy Sherman does not title her photographs or you might want to see a movie before you read the reviews or read a book before you watch the movie. To see Kate Winslet and Leonardo DiCaprio in the film version of Revolutionary Road before you have met April and Frank on the page can deprive you of forming your own images of the couple, of experiencing their pathos on your own terms. In the therapy situation, your inner life — your fantasies, imaginings, interpretations — are the very material you will explore. Do you really want to flood this fragile garden with Google runoff?
For this not to happen, you will need to draw upon that fusty old-fashioned virtue of restraint. Odd as it may sound in this day when your dinner companion might pull out a smart phone to find the name of an actor in a 40-year-old film, as though the atomized piece of information trumps the flow of ideas and feelings in the moment, being curious about something does not mean you have to satisfy that curiosity. You can choose not to read your children’s journals, the letters that arrive for your roommates, your partner’s emails. The mother of a kindergarten child once confided that during the summer prior to her child entering school, she had Googled every parent in the grade, thereby learning that there were seven families with a net worth of over a billion dollars — covetous information gained at the cost of connecting as a fellow parent sharing the profound experience of raising a young child. Similarly, in the service of your treatment — the relationship you will be forging with your own inner life — you can choose to refrain from Googling your therapist.
Know, too, that even if you leash yourself so as to allow your curiosity to flower in the treatment, life may still interfere. You might bump into your therapist at the movies, in a restaurant, maybe even in Paris or on an airplane. A near-sighted supervisor used to tell a story of stumbling naked from the shower after a swim, blind without his glasses, only to hear his patient’s gleeful “Hello, Dr. C.” Trainees were mortified on his behalf. They were missing the point, he gently chided. What mattered, as far as the treatment went, was the patient’s glee, not the therapist’s birthday suit.
All fine and good, you say, but you and Google are like a child and a bag of jelly beans and you have already put your hand in the bag or are certain that when 2 a.m. rolls around you inevitably will. Be aware, then, that what you have found or will find may be no more reliable than real estate advertisements and — here is the paradox — will ultimately be only what therapists call “grist for the mill.” Talk about it with your therapist. Investigate your curiosity. After all, you are the reason you are paying dear money to see your therapist — and, you will discover, you are more interesting than any Google fishing trip.
Maurice Preter, MD is a European and U.S. educated psychiatrist, psychotherapist, psychopharmacologist, neurologist, and medical-legal expert in private practice in Manhattan. He is also the principal of Fifth Avenue Concierge Medicine, PLLC, a medical concierge service and health advisory for select individuals and families.
We pride ourselves in providing exceptional quality of care, access, comfort and privacy to our patients.