Mind: Recalibrating Therapy for a Wired World - The Digital Doctor

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.

Dr. Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College in Manhattan.