In my training as a psychiatrist and psychoanalyst, I’ve learned to pay close attention to the details: I notice when my patients change their tone of voice, when the flow of their ideas shifts direction, or when they seem to enter a new emotional state. This focus on my patients is essential to doing my job well, but it also may have obscured something significant: the way they interact with their phones.
Recently, I’ve begun to wonder how smartphones have impacted my relationship with my patients and how I practice. It’s something I didn’t even have to consider when I first started in the field — but the transformation over the years has been subtle, stealthy, and powerful, as cell phones have morphed from just telephones into powerful computers that can instantly summon information, answer complicated questions, and record long streams of communications between people.
If I were writing this article 10 or 15 years ago, in the age of simple flip phones, I might have talked about how the quiet of my office space was now punctuated by beeps, pings, buzzes, and musical flourishes — or how the ringtones people chose might serve as tells, providing insight into their personality. A syrupy pop song emanating from a patient’s phone, for example, may suggest a previously unknown playful side. (In my own experience as a patient, my serendipitous discovery that my analyst and I had both the same phone and ringtone led to elation: He and I were indeed in sync.)
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More interesting than the ringtone, though, may be how a patient chooses to handle an incoming call during their session. Over the years, as I’ve started to pay more attention, I’ve noticed that the strategies vary fairly dramatically: For some of my patients, an inopportune call is a chance for them to demonstrate that they are involved in something significant that takes precedence over their time with me — or, conversely, that nothing comes between them and their session. How patients describe where they are to the person on the other end of the line can also be revealing. Some will proudly announce, “I’m with my psychiatrist,” or even identify me by name to the other person. Others are more opaque: “I’m in a meeting,” or, “I can’t talk right now.” Inadvertently, they’re letting me know how they feel about our sessions, and what they imagine others would think.
As a result, I don’t ask my patients to silence their phones. Even if I did have a no-phones policy, though, I doubt I could enforce it: These days, many professions demand continuous accessibility. Many of my patients are physicians, for example, and need to be contactable, even if they’re in a session. Although the analytic office remains a confidential space for patients, it is no longer necessarily a place where they cannot be reached.
Having ready access to their phones during treatment also means that the phone can serve a defensive purpose, a sort of buffer for patients against stress or unwelcome information. I’ve seen plenty of patients suddenly take out their phones in an attempt to distract themselves and me from an interpretation I just made. And because analytic offices, like casino floors, seldom have a clock visible, a quick glance at a phone can offer a reminder of both the hour and the existence of an outside world — an antidote to the anxiety that can accompany the suspension of time that occurs in a session.
On the other hand, the advent of the smartphone has given many of my patients a new way of connecting with me during their session, one that wasn’t possible with simpler cell phones. Rather than just describing an interaction with another person, some patients will pull the evidence out of their pockets, showing me the text messages or emails relating to the encounter. They want to know: How did they sound? What did I think of the other person’s comments? Did I think their point was clear? This approach has its advantages, but it also comes with a major drawback: By reading directly from a digital exchange, patients don’t exercise their imagination or memory. As difficult as it can be for a therapist to know the motives of someone who’s not in the room, the often-ambiguous nature of text messages and emails can make that interpretation infinitely more difficult. To help my patients turn their focus inward, I ask them: “What do you think you wanted to learn or convey from reading those messages?” Similarly, when patients want to show me a picture of how they looked at a particular time, I encourage them to put their feelings about the picture into words.
It can be frustrating for them. But the therapeutic process is frustrating by design, a fact compounded by the therapeutic taboo against touch. Intense feelings can emerge during a session, but to protect both patient and therapist, the physical contact that such feelings can invite — a hug, say, or a comforting pat on the back — is forbidden. In our field, any touch between patient and therapist is confined to the exchange of pieces of paper: bills, checks, and prescriptions. And even those points of contact are fast disappearing in some places: In New York State, mandatory electronic prescribing has killed off the old written paper prescriptions, and bank-generated payments have made the handoff of a physical check at the end of a month less common. The seemingly innocuous act of a patient handing you their phone in a session, then, may represent a wish to circumvent the physical barrier and achieve a tangible connection that the therapeutic process does not allow.
But the power of someone handing you their phone — and the trust that it implies — is not to be underestimated. Cell phones have come to be seen as extensions of their owners: They contain repositories of personal images, past and future schedules, and serve as a means to communicate with others. In that way, they’re kind of like physical representations of the human mind. In a therapy session, we ask patients to look closely at themselves in an effort to know themselves better; what we’re still trying to figure out is whether the development of powerful personal machines like cell phones will make that process easier or more complicated.