The job of the psychotherapist is, in no small part, to help the patient find middle ground between extremes. This is what Janet Malcolm called “the freedom to be uninteresting.” When the patient can imagine more ordinary ways of being than the Gothic binaries of love/hate, depression/mania, or serenity/suicide, she begins to discard oppressive patterns of behavior in favor of living like herself.
The same philosophy should be applied to considering the role of technology within the psychotherapy context: it is not pathology or balm, but something in between, and what that something is depends entirely on how it is used.
Patients know they have your cell phone. Patients will text you. Patients will search you on the internet. Patients will find out what they can. Patients will ask you to Skype or FaceTime them. Patients will use any of this technology, which becomes part of the transference. Why shouldn’t they? And why shouldn’t the technology be absorbed into the treatment?
In psychoanalysis, the question of technology and media is the question of transference. Strangely enough, the German term for transference—“Übertragung”—is also used for “transmission” in the sense of technical media, as in “live transmission”— “Direktübertragung,” or more commonly, “Live-Übertragung.”
“Übertragung”—“transmission,” “transference”—also means “metaphor.”
I actually find texting much more efficient than returning voicemails and playing phone tag. Even returning an email takes more effort to do than text. Particularly for teenagers, texting is very familiar with them. I’m happy to meet them where they are at, because they’re not going to call me, and even if I leave them a voicemail they’re probably not going to listen to it.
The one thing I’ve heard people worrying about is: What if you missed a text that was about suicide or some other kind of safety issue? But I think that the same thing can be true of a voicemail, especially if you’re using your work mail in your office. You’re not going to be checking it non-stop. I’m not going to check a voicemail in the middle of a meeting. But if I get a text, chances are I have my phone on me. I very rarely miss a text and so I find that it’s actually safer. I work with a lot of high-risk people who have chronic suicidality, so it actually matters for me.
I have few if any inviolable rules regarding technology in my practice. When a patient is out of town we may opt to hold sessions via Skype, acknowledging that while video chat is less sacrosanct than meeting in person, it is a far closer approximation than speaking by phone, and above all preferable to not having a session at all. Patients frequently email me; particularly in handling logistical issues I find it more efficient than volleying voicemails back and forth. Even if an email contains more personal material, this is “allowed”—by what right could I forbid it?
If a patient sends a provocative email, checks her phone in the middle of a session, or spends a great deal of time discussing the intricacies of her life on social media or in video games, I regard it, first and foremost, as meaningful. In one way or another, the patient is showing me who she is and how she relates to others.
Different technologies like social media show up as the content of what you are working through with patients. I would say the biggest thing that we get is parents wanting to either monitor or restrict what social media platforms are okay for their kids. I think that when you’re talking about an eight-year-old with an Instagram account, it’s completely appropriate and reasonable that their Mom is going to follow them on it.
But once you get up into eleven, twelve, and beyond, I don’t think it’s realistic for parents to monitor them on everything. Kids find ways around it, or they have multiple profiles. They’ll do whatever they need to do to have their own space. I also don’t think it’s appropriate developmentally. I try to talk to parents about the developmental trajectory of using social media, and it shifting from monitoring to being more about trust and conversations. That’s really, really hard for some parents. Some totally get it, but others are still like, “Nope, I’m going to monitor them on everything, I own this phone, I pay for the internet, therefore I get full access.” Usually that doesn’t work out.
Parents will think that social media causes their kids to have X, Y, or Z problem. But usually the kids who are getting into serious problems on the internet with sexting or cyberbullying are having problems in other non-technological realms. And some parents don’t want to accept that. It’s much easier to scapegoat the technology.
Understanding how technology intersects with the lives of patients and the broader culture is necessary extracurricular work for the psychotherapist. If I were to treat someone deeply embroiled in the world of Tinder, it would behoove me to at least have some idea of what Tinder is. More important would be the need for me to feel curious about what Tinder is to my patient, and not dismiss anything I don’t understand as corruptive or puerile, for to do so would be to dismiss a part of my patient’s life.
My rule, if you can call it that, is that a patient is free to say whatever they like, however they like, and I am free to respond (or not respond) in whatever way I think will benefit the treatment. For instance, I will rarely respond to an email or text message from a patient other than to acknowledge its receipt, and perhaps suggest that we discuss its contents at the next session. Many things happen in the asymmetric, virtual space that defines modern communication—ranging from the wonderful to the horrific—but not, I think, psychotherapy. The patient has enlisted me to bear witness to her experience, which demands my presence and undivided attention.
Technology can help this purpose—by keeping us connected even when physically apart—or present new conundrums. But it can neither destroy nor replace the emergent power of two people sitting in a room together, attempting to chart a course between extremes.
There are two extremes:
Language, or rather speaking, is the medium of psychoanalysis. Its space is saturated with “speaks.” Everything in it speaks: silence, sounds, furniture, clothes—they all speak. Nothing is not speaking in the setting of psychoanalysis. The patient doesn’t show up—that’s speaking. He says “I hate you”—that’s not what it says alone. She dreams—that’s speaking.
So why not speak, yell, or not be there—on the phone? In a way, there is no difference.
The bodies are there, by necessity, and without language. You have to be in a shared room and share the space.
The classical setting for psychoanalysis (couch, facing opposite directions, free-floating attention), combined with voice, gaze, and touch, is a felicitous compromise between these two extremes. But it is only a compromise. And since this is only a compromise, there are others. A walk, a phone, a hotel lounge. The setting can be transposed, transferred, transmitted, and metaphorized. Into phone sessions, for instance.
You can never trust the setting nor can you trust just the medium or means of communication.
In a way I’m very laissez-faire about technology, but only because I seriously believe in structure: structure as something that is created by the treatment. There is the same laissez-faire attitude about technology in Freud, from Civilization and its Discontents:
If there had been no railway to conquer distances, my child would never have left his native town and I should need no telephone to hear has voice; if travelling across the ocean by ship had not been introduced, my friend would not have embarked on his sea-voyage and I should not need a cable to relieve my anxiety about him. What is the use of reducing infantile mortality when it is precisely that reduction which imposes the greatest restraint on us in the begetting of children, so that, taken all round, we nevertheless rear no more children than in the days before the reign of hygiene, while at the same time we have created difficult conditions for our sexual life in marriage, and have probably worked against the beneficial effects of natural selection? And, finally, what good to us is a long life if it is difficult and barren of joys, and if it is so full of misery that we can only welcome death as a deliverer? It seems certain that we do not feel comfortable in our present-day civilization, but it is very difficult to form an opinion whether and in what degree men of an earlier age felt happier and what part their cultural conditions played in the matter.
For Freud, technology and progress seem to be at odds with the pleasure principle. The idea that they create more happiness is wrong at best, and a destructive illusion at worst. This is something that you hear in analysis: patients come up against the illusion that technological life is supposed to make them happy, make living easier or more fun, help them find the perfect life or the perfect match.
The question is whether they make this disappointment personal—whether they see it as their own failing to find the happiness that they think everyone else must have (FOMO) thanks to all this wonderful technology, or whether they encounter something else about what it means to be human.