Digital transference: New dangers in a new world


We are in a new age of psychiatric practice caught in the wider shift from an industrial to a technology-based society. Although this transformation has been occurring over the past half-century, the last decade has seen a rapid acceleration driven by mobile phones, social networking, and the Internet.

Thomas Friedman, in his book “Thank you for Being Late: An Optimist’s Guide to Thriving in the Age of Accelerations” (New York: Farrar, Straus & Girous, 2016), cites 2007 as the year our world changed with the launching of the iPhone, the globalization of Facebook and Twitter, the release of the Kindle and Android, the founding of Airbnb, Google’s purchase of YouTube, and IBM’s creation of its AI system, Watson. Psychiatry has been gradually incorporating technology into everyday practice using mobile devices, email, videoconferencing, Internet, and electronic medical records, as well as being impacted by more rapidly evolving technologies, such as texting and social networking platforms.

Dr. Jay H. Shore

Dr. Jay H. Shore

The 21st-century psychiatrist will need to become adept at managing the doctor-patient relationship across a hybrid of different technologies. The processes and interaction that encompass the doctor-patient relationship are no longer limited to in-person contact and occur across a variety of formats, including in-person, via videoconferencing, email, text, web-based patient portals, and mobile phones. Despite the shifting nature of psychiatrist-patient communication, little is known about the impact of the “hybrid relationship” on clinical processes, such as rapport, understanding, and transference.

Transference remains a core tenant in the psychiatric conceptualization of the psychiatrist-patient relationship. There are numerous formal definitions of this phenomenon. This article will use a broad reductionist definition of transference as the “unconscious projection of a past relationship/experience onto a current relationship” and combine the terms transference (from patient to psychiatrist) and countertransference (from psychiatrist to patient; often defined as a psychiatrist’s reaction to a patient’s transference).

How do a psychiatrist and patient dyad’s previous experiences with technology and technology-based relationships affect a current clinical relationship? How does the type of technology being used influence shared meanings and assumptions? Does technology introduce new implicit biases that go unrecognized? Does distant communication increase the risk of missing contextual clues more apparent for in-person interactions? These critical questions have largely gone unaddressed, but what is known raises concerns. The question is not whether to use these technologies, which have demonstrated utility to transform care. Rather, concerns around our lack of understanding of the technologies’ strengths, weaknesses, and influences on the doctor-patient relationship need to be explored. Below we will briefly examine each of these questions.

A relatively new paradigm has been inserting itself from the field of education into medicine that describes a patient’s previous technology experiences. “Digital immigrants” is a term for those who did not grow up with today’s technology and began using our current technologies as adults. They contrast with “digital natives,” who have grown up incorporating technology into their daily lives. Broad assumptions are that digital natives tend to be more comfortable, flexible, and adaptable with technologies, compared with digital immigrants, who are more hesitant and slower to adopt and integrate technology. However, the experience of a specific patient with technology is multifactorial and more nuanced than the digital native vs. digital immigrant classification. There are those who argue that technology use from an early age is altering on a biological level the way the human brain processes both information and emotion. Depending on their experiences and backgrounds (immigrant vs. native), a psychiatrist and patient using videoconferencing to enable remote access could have initial as well as ongoing positive or negative transferences to treatment.

The specific technology being used also sets parameters for communication that influence interpretation. Text and email communication are very different from live interactive video conferencing and involve use of language that may not be shared between the psychiatrist and patient, such as text abbreviations and emojis. Lack of visual and auditory information necessitates more interpretation by the receiver to fill in tone, meaning, and intent drawn from their past conscious and unconscious experiences and assumptions. The opportunity for misinterpretation is further compounded by implicit bias built into the technology. Although biases embedded in medical technologies have yet to be examined, there are some alarming examples from society in general.

A recent report by the Georgetown University’s Center on Privacy & Technology drew attention to inherent racial bias in facial recognition technology used by law enforcement agencies. This bias was a product of both the underlying software and programming, as well as the real world implementation of these systems. As the field of medicine increasingly turns to artificial intelligence for help with pattern recognition, data management, and population health, what implicit biases are being built into these systems? Could a web-assisted, evidence-based therapy that uses an algorithmic approach have built-in biases for certain populations of patients, affecting the therapeutic interaction?

A final issue worth considering is the power of technology to distort shared context. When a psychiatrist meets with a patient in person, they are sharing the same environmental context at the same point of time during treatment. When communicating over distance, they are occupying different environments and, with asynchronous communication (for example, email), different points in time. These disparate contexts may lend themselves to additional assumptions that get projected onto the clinical relationship. For example, a telepsychiatrist working with Northern Plains Indian Communities via videoconferencing has a new patient in a new clinic setting visually similar to other clinics they have visited in the past. If not mindful of context, the telepsychiatrist may risk making unwarranted assumptions about the patient’s environmental context based on the physician’s previous work. In a different example, a psychiatrist sees a patient for an in-person visit and then reads an email sent 12 hours prior to the visit by the patient expressing upset at psychiatrist’s structuring of treatment. This issue was not addressed in the session that just ended. What is the impact of this email to both the psychiatrist and patient, and their current feelings about the therapeutic relationship? Is this now current or past context for the patient and psychiatrist?

For many, questions about bias, context, and previous experiences with technology can be seen as “grist for the mill” for psychiatrists to understand the transferences and other processes within doctor-patient relationships. This knowledge can then be leveraged to appropriately attend to the therapeutic relationship. The danger in the age of hybrid relationships is when there are embedded issues that psychiatry as a field and individual psychiatrists are unaware of and not attending to in treatment. As the acknowledged experts in medicine in the doctor-patient relationship say, psychiatrists need to take leadership roles in better understanding the impact of technologies on clinical processes – both for those processes on the surface, as well as those that lurk beneath the digital waves.

Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also serves as associate professor of psychiatry at the university.

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