Who’s Listening? Smartphones and Psychotherapy

Who’s Listening? Smartphones and Psychotherapy

by Maggie Mulqueen
Maggie Mulqueen asks fellow therapists to consider the good, bad and ugly of client cell phone use in session.

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We both hear the buzz. I watch as he reaches over to the table to pick up one of his phones to see who the message is from. First, he checks his work phone, then his personal phone. I observe the tension in his face and try to hold on to the moment we just lost. It is 7:15 in the morning. He tries not to work during our sessions, but the financial overseas markets are already open, and his work expects him to be available. He does not mean to be disrespectful. I get more of his undivided attention than anyone else, but still I feel frustrated at being put on hold.

No-Smartphone Zone

The therapy hour is the patient’s and it is sacrosanct. In addition to the therapist’s training and expertise, what the patient is buying is fifty minutes of her undivided attention. In the not-so-distant past, the therapist used to receive her patient’s undivided attention as well. But no more. Smartphones have transformed the therapy hour, at least in my practice.

Smartphones have transformed the therapy hour, at least in my practice
Therapy sessions are a laboratory for understanding human relationships. In addition to the patients’ individual needs, larger cultural trends are exposed in a therapist’s office. Personal devices have simultaneously enhanced and impaired human relationships. Helping our patients (as well as ourselves) adapt to the ever-changing world of technology is essential to functioning in our society. Examining patients’ relationships to their personal devices within therapy sessions sheds light on various ways technology is changing private and public lives.

Being unavailable for as little as an hour without fear of repercussion is no longer possible for many people. In the workplace, schools and within families, we are always expected to be available. Even patients with a standing weekly appointment, who are accustomed to the routine and sanctity of the therapy session, are often interrupted during a session with a non-emergency request. For a few people the consequence of being unreachable is truly unacceptable, but for most, having their smartphone on is merely a habit.

So why not simply have a policy that bans smartphones during therapy, as some of my colleagues do? I forbid anyone to smoke or use drugs during their sessions and I am comfortable enforcing those rules, so why don’t I enforce a rule about cellphone use? I imagine that some of my patients would balk at a prohibition on smartphones in my office. I also don’t want to spend the beginning of each session negotiating whether the potential need to be interrupted rises to the level of granting an override to my ban. But, perhaps more importantly,
I learn things about my patients as I witness their relationship with their phones
I learn things about my patients as I witness their relationship with their phones. At this point I have no official policy, but rather have incorporated my observations of how my patients use their smartphones into my general understanding of how they function in the larger world. Understanding how people relate to technology reveals important aspects of their values and personalities.

The smartphones—and yes, some people bring more than one—may be out in full view, or they may be stuffed into pockets, handbags or briefcases. On occasion, if they have been inadvertently left in the car, patients excuse themselves to retrieve the phone, “just in case.” It’s not just the phone ringing, but the ping of incoming texts, voicemails and emails that punctuates the session. Increasingly, people wear smartwatches that light up with each incoming text or email notification, adding to the distraction. People claim that they need to have their phones on in case of an emergency, but rarely does the interruption meet that bar. In fact, in over thirty years of practice, I have only twice had situations where a patient had an actual emergency which necessitated leaving the session early. This underscores that
technology has changed the social norms for what constitutes an emergency
technology has changed the social norms for what constitutes an emergency. Prior to cell phones, people came to the therapy hour with less worry and distraction about being reachable. There was an implicit understanding that for fifty minutes the world could take care of itself without dire consequences.

GoPhone or StayPhone

Our relationship to our devices is embedded far deeper in our psyche than most of us would care to admit. Thinking of our phone as merely an appendage, like the car keys, denies its emotional connection. This is part of why people feel so unsettled if they can’t find their phone or if the phone is off. It is as though they’ve lost a part of themselves. A recent study in the Journal of Social and Clinical Psychology discussed how limiting social media access could decrease anxiety and depression. It is both the content of what we are seeing as well as the need to be incessantly looking that is impacting our mental health. The understanding that constant connectivity is hurting us is gaining traction, but that does not mean people can easily go cold turkey for an hour a week. Counterintuitively, by allowing smartphones to be out and visible during therapy sessions, some of my patients are calmer and more focused than they would be if left to wonder who might be trying to reach them for that hour.

During my work hours, both my landline and my own smartphone are silenced. Before cell phones existed, patients would occasionally ask me to turn on the ringer to my landline, so a babysitter or physician could reach them if needed. But at that time, the norm was that there was no need for interruption during the session and our time together was the central focus. The patient-therapist relationship was built on the communication that occurred between us in the office.

A colleague reports, “For those who peek at their phones throughout sessions, it feels like a compulsion—they can’t not look.” Some people glance at their devices during sessions to read incoming texts and missed calls throughout the session—as a form of multi-tasking—seemingly unaware of how such behavior disrupts the flow of conversation or limits the emotional depth of our connection. Patients have always had ways of side-tracking themselves during sessions, such as changing the topic, glancing out the window or playing with a tissue box, but the smartphone provides a far more powerful distraction.
Its addictive properties and prevailing social norms that permit having it on at all times contribute to using our smartphones as a psychological shield
Its addictive properties and prevailing social norms that permit having it on at all times contribute to using our smartphones as a psychological shield.

He takes notes on his phone after their fights because he wants to make sure I hear “both sides.” He is a chemical engineer by training and committed to getting the facts right. He “walks on eggshells in their marriage,” scarred by her words and blind to his own rage. He reads his notes to me during each session, a practice he finds reassuring, confident that he has gotten the wording just right.

Sometimes patients use their phones in therapy to bolster their position on an issue. They want me to agree with their outrage over someone’s insensitive comments or their disgust with inappropriate pictures shared on dating apps. I wonder if people have ever thought about the possibility these photos could be shown to a therapist before posting them. Just as people no longer rely on their memory for phone numbers or directions, whole conversations are readily available to be shared. The story doesn’t unfold. Rather, the evidence is presented like a legal argument. Many of my colleagues have acknowledged the beneficial aspect of this—it allows for a truer glimpse into the patient’s behavior in the outside world. But it can also easily thrust the therapist into the role of judge, rather than allowing for a more nuanced dialogue. For example, at the end of reading a text exchange aloud, the patient may look up from the screen with a fervent expectation that I will be nodding in agreement. This feels entirely different from a story being told in the patient’s own words while maintaining eye contact with me. In an effort to highlight the patient’s reaction, rather than offering my response right away, I typically ask the patient to reflect on what he just read.

Occasionally, patients are genuinely confused about how to interpret a message. They search on the phone for a text or email and read it to me. “What did she mean by this text? Is she trying to break up with me?” “How could he think that was funny? He claims it was a joke.” “How long should I wait before texting back? I don’t want to appear too eager.” Integrating this ever-changing technology into our relationships requires that all of us write the instruction manual in real time. I am not the Ms. Manners of smartphone etiquette, but I think people are turning to their therapists for help in this regard because we are experts in relationships. On a recent episode of the podcast The Cut, “Bad Sex, Good Sex: Fiction That Makes Sense of How We Bone” (2019), one of the panelists reported that she brings her phone into her therapy sessions because she was explicitly looking for help from her therapist with how to interpret the text message exchanges on her dating app. No longer was she relying on her own experience, but rather she read the text exchange aloud looking for help with interpretation. She said, “All therapists need to get hip to this because it’s not just crazy assumptions anymore.” The fact that it is now “he said, she said” in black and white rather than one person’s recollection can add powerful information to the session. The panel went on to discuss how important it is for therapists to be knowledgeable about the varied ways emojis are used.

Therapists have a deeper understanding of our clients’ issues than an advice columnist. For example, someone who is conflict-avoidant would much rather send a text than make a phone call when there is tension in a relationship. As professionals,
being fluent in how smartphones and other forms of technology are used to foster social connections is critical to offering relevant assistance to our patients
being fluent in how smartphones and other forms of technology are used to foster social connections is critical to offering relevant assistance to our patients.

By making us more reachable, smartphones have increased not only our ways of communicating (a simple “I’m sorry” text on the way to work can ease an early morning fight), but also the expectation that a recipient should respond ASAP. It can be excruciating to wait for a response and people often have a strong reaction to a real or perceived delay in response. Family members, friends and bosses text or email rather than waiting for an opportunity for face-to-face conversation. Sometimes, phones are used in this way to control the communication, pounding out a monologue and hitting send rather than welcoming a dialogue. Patients can use their smartphones as a verbal weapon when they impulsively bombard someone with a rant. Alternatively, being “ghosted” can erode one’s self-esteem. Learning how to interpret both the content and the timing of someone’s texting behavior is on par with learning a new dialect. All these new ways of communicating are significantly altering how relationships are formed and nurtured.

Commenting on the absence of my smartphone during our sessions, one of my college-age patients recently told me, “You’re the only person I talk to who actually looks at me the whole time.” This statement opened a discussion between us about her relationship to her own phone. As Cal Newport wrote in The New York Times (2019, January 25) earlier this year:

Under what I call the ‘constant companion mode,’ we now see our smartphones as always-on portals to information. Instead of improving activities that we found important before this technology existed, this model changes what we pay attention to in the first place—often in ways designed to benefit the stock price of attention-economy conglomerates, not our satisfaction and well-being.


Many of my patients have expressed a desire to spend less time on their phones but feel uncertain about what the consequences for their social life might be. As more people experiment with “Dry January,” could we imagine a social movement toward “Smartphone-free September” where we return to using our Smartphone only as a phone?

Early in my training as a psychologist, a supervisor taught me that he waited 24 hours before returning a phone call from a prospective new patient. He explained that he wanted to “set the stage with realistic expectations about his availability.” I have continued that practice, but recently I have begun to wonder if the wait for a call back feels different to potential patients in this day and age. Do they just “swipe left” and move on to the next therapist’s profile? It is also interesting to see how long a week between sessions feels to different patients. The timing of sessions is always part of the treatment protocol, but in a landscape that is more 24/7 than ever and with so much instant connectivity, waiting a week to continue a conversation is no longer representative of how most relationships function. Increasingly, and counterintuitively, because we will sometimes communicate between sessions, I find I have to remind patients about what happened in past sessions to keep the thread of our in-session work alive. This is a change from earlier in my practice when our time together week to week was more demarcated. Now people are “in touch” with such frequency that it can be harder to hold onto what was said in the session as opposed to all the noise in between. To combat this, I encourage patients to organize their day in such a way that they have time after each session to quietly contemplate our work rather than squeezing it in between all the other parts of their lives. Sometimes
I explicitly encourage someone to not reflexively check their phone the moment the session ends, but rather give themselves time for reflection
I explicitly encourage someone to not reflexively check their phone the moment the session ends, but rather give themselves time for reflection. By delaying the inevitable distraction created by reentry into their busy lives, patients can make much better use of their therapy sessions. Ironically, this suggestion is undermined by using the smartphone as a calendar. As soon as patients turn on their phone to make an appointment, they are greeted with all the missed communications of the last hour. Consequently, the session ends abruptly even before the person has left my office.

Worth a Thousand Words

Her son is worried that he is getting fat. She is worried that her own body image issues are scarring her child. She reaches for her phone and offers to show me photos of her family. Her eyes reveal the fear she feels anticipating I will judge her as a bad parent.

With the introduction of photos on phones, I feel that I’ve graduated from radio to television in my sessions. Patients may hand me their phone to look at photos during a session. At times this can involve an awkward dance as we negotiate how to be physically next to each other. Do I get up from my chair or do they come over from the couch to me as I am introduced to the family? Because I usually hear the details of someone’s personality long before I see a photo of them, I often draw my own picture of the person’s appearance, sometimes finding out how wrong I was when I see their image. For example, a tyrannical father may have been only a few inches taller than my patient, but his forceful behavior had me visualizing him as much larger.

There have been occasions when I’ve asked to see an image of someone, such as after the death of a parent, as a way of feeling closer to my patient. Patients sometimes solicit my reaction to the photos they share, but in my role as therapist I always try to reflect to the patient that their opinion is the one that matters. It can be illuminating, though, to see the discrepancy between someone’s self-report and an actual image.

Sharing photos from major life events of my patients can also foster joyous connections with them. In many instances the result of our work was critical to the realization of a wedding day, a baby or a graduation. Prior to smartphones, patients might have brought photos with them to a session in a planned way to share these significant events, but now there can be the spontaneous sharing of a child’s first steps or the photo of a new home.

The availability of photos and videos on phones has also increased how much of my patients’ lives I can share virtually. I have heard musical performances, comedy routines and graduation speeches. I now have greater access to the full scope of my patients’ lives as they send me updates through texts or emails. In addition, the exchange of podcasts and articles to supplement the therapy hour can be beneficial, just as book recommendations have been. But this necessitates that I manage patients’ expectations about my availability between sessions. Sometimes people want me to read or listen to information as a way of getting to know them, rather than relying on the work we do together during the therapy hour. Potentially this can speed up the connection we have together, but there are other times when it feels like resistance to actual therapy.

Incidental Eavesdropping

In an effort to contain how my patients reach me between sessions, I am judicious about sharing my email address or cell phone number. Historically, all these ways of interacting would be considered “grist for the mill” in a therapy relationship. To an extent they still are, but I think it is important to monitor how effective the access to technology is for improving or hurting therapy relationships. An article in Forbes.com, “Sleepwalking Towards Artificial Intimacy: How Psychotherapy is Failing the Future” by Essig, Turkle, and Isaacs Russell (2018, June 7), articulates the slippery slope therapists are on when their behavior contributes to the notion that human interaction can be replaced by technology. From scheduling appointments to responding to patients’ requests with our own text messages, we are succumbing to the ease of using technology and missing the fuller exchange possible in a phone call or face-to-face meeting. When therapists’ behavior reflects social norms regarding technology rather than challenge it, the authors conclude, they are failing their patients.

we are succumbing to the ease of using technology and missing the fuller exchange possible in a phone call or face-to-face meeting
She reads the text thread on her daughter’s account from her own phone as she tells me about how worried she is that her daughter will be expelled from boarding school.

Recently, one of my patients was complaining that her daughter, who is enrolled at an expensive private high school, was on her device during class time. The mother, my patient, is able to track her daughter’s use of her phone clandestinely. She saw that her daughter did not use her phone during lunch or free periods, when presumably she was having face-to-face contact with friends. When my patient questioned the school about their policy for the use of personal devices, they stated that they choose not to police students’ phones but rather to teach students how to police themselves. Ironically, the mother and I had this conversation while her own phone was lighting up with text messages to her from her daughter and she was paying me for my time. When I pointed out the contradiction between her unhappiness that her daughter was not paying attention in class and her own choice to be on her phone during our sessions, she grew quiet. She was so concerned about being available to her daughter at all times, she had failed to see how she was modeling exactly the behavior she does not respect.

I listen as he talks to his wife. I am a silent observer to one side of the conversation. I can see his facial expression and body language. I hear the frustration in his voice despite the polite language he uses. I wonder if she realizes how close he is to leaving her.

Once, a patient who was going through a nasty divorce continued his phone call with his wife for the first five minutes of our session. He was on his phone as he entered my office and, without acknowledging my presence, continued the conversation. I had heard him describe his frustration and hurt, but to actually hear the anger in his voice and see the veins in his neck throbbing as he shouted at her brought his pain vividly into the session. We are all privy to overhearing phone conversations with little regard for privacy as we go about our day, but hearing snippets of conversations can reveal aspects of patients’ personalities that otherwise might have stayed hidden far longer.

The Newest Addiction

Increasingly, the very topic of addiction to smartphones is the presenting problem in therapy. Patients are looking for help to manage their addiction to the use of the device and/or the content on the device. Hours are spent on pornography, dating apps and/or social media. People spend time chasing down news stories, only to find themselves more depressed than ever. In these cases, a discussion about the presence of personal devices during the therapy hour is essential. Some of my colleagues have a basket in their office with the expectation that patients turn off their phones and drop them in the basket. One colleague, who works primarily with adolescents, told me, “This (dropping phones in baskets) is so routine for them—at school, friends’ parties—they never question this expectation. My adult patients are much more likely to balk at the request with protests of needing to be available “in case of an emergency.”

Patients complain of partners who take their phone to bed and are text messaging with someone else or looking at the Facebook posts of friends as they lie there feeling ignored. Or they engage in parallel play, side by side, watching their own TV show or film. Single patients will talk about the hours they lose to being on their smartphones. It is easier to play another game of Candy Crush than meet a stranger for a date.
Feeling connected to the world virtually makes staying home feel less isolating, but it rarely touches their deep loneliness
Feeling connected to the world virtually makes staying home feel less isolating, but it rarely touches their deep loneliness.

Even though she knows “it’s crazy” she reflexively checks to make sure her phone is off before talking about her mother. She is terrified that her mother might hear what she is saying.

There are those patients who religiously turn off their phones and direct their full attention to our work from the beginning of each session. I have yet to find a way to predict this behavior by age, gender, profession or presenting problem. I’ve talked to other therapists and they say the same thing. Some patients eventually adopt this stance on their own. As the work gets deeper and our relationship closer, they invest more thoughtfully in our time together by turning off their phones, whereas in the beginning of treatment they may not have been as ready to do that. Some express relief to be away from their devices for an hour and to focus on themselves. Sometimes, when I observe a patient nervously looking at her phone, I may ask her if that is really how she wants to spend our time together. Turning off the phone can be an assertive act and contribute to enhanced self-esteem. It may also generalize outside the therapy office, giving people permission to ask others to turn off their phones for the purpose of decreasing interruptions or staying focused in a face-to-face conversation. Much like the transition from allowing people to smoke everywhere to limiting smoking to designated spaces, I find people are starting to long for a social change where they feel more empowered to ask people to turn off their phones. The quality of the conversation we have during therapy can become a benchmark for the kind of conversation people want to have with other people in their lives. Just as I encourage patients to meet someone for a first date at a coffee shop rather than a place where alcohol is served, discussing how to limit smartphone use before engaging in a difficult conversation seems critical to increasing the likelihood for a successful interaction.

She asks me to slow down as she types my words into her phone. She tells me that she reads them between sessions to remind herself that she has a right to exist.

A Place on the Couch

Smartphones are not the enemy of psychotherapy. In fact, therapy can illuminate how technology is changing the social fabric of society, especially relationships. Psychopharmacology was once seen as a threat to “talk therapy,” but it is now clear that they complement each other. Technology expands the possibility for people to receive treatment in remote areas where there may not be many providers. Through the introduction of Skype, FaceTime and other applications which allow for both visual and verbal communication, patients can have sessions during extended periods of being away. Recently, insurance companies have started to reimburse for teletherapy, thus making it easier for potential patients to find a provider. Although I still prefer to meet with people in person, there have been instances when, because of technology, I was able to continue working with someone, such as when a patient studied abroad for a semester, despite a geographic separation.

Linda Rodriguez McRobbie of the Boston Globe (2019, January 31), reported on a relatively new development- apps that deliver therapy without a therapist; the therapist in your pocket. People use their smartphones to establish meditation practices, exercise routines and various other self-help functions. Cognitive-behavior therapy principles are available to download as an alternative to actually engaging in therapy. Our reliance on our smartphones to fulfill our needs, even going so far as replacing human interactions, is troubling. Perhaps the best example of how seductive a relationship to a smartphone can become is revealed in the 2013 Spike Jonze movie, Her, (where the main character falls in love with his phone and takes it on dates).

Adapting to change is a hallmark of therapy. Therapists are in a unique position to experience as well as reflect on how human connections are floundering or flourishing by the presence of technology in our lives.
When technology enhances our connections, relationships blossom, but when technology becomes an overwhelming focus of our lives, relationships suffer
When technology enhances our connections, relationships blossom, but when technology becomes an overwhelming focus of our lives, relationships suffer. The therapy hour can serve as a reprieve from being available, a training ground for practicing a phone-free hour. Ironically, I, of course, have my smartphone silenced and out of sight throughout every session. The person in front of me deserves my full attention and my behavior models that it is still possible to be unavailable to the larger world for an hour.

As I struggle with the reality that technology is omnipresent and ever-changing, I also continue to believe in the power of human connection. One of the benefits of a psychotherapy relationship is its consistency. Every week I show up at the same time ready to listen to the deepest thoughts and feelings my patients choose to share. Together, through our connection, I explore the needs and desires expressed by them to support their change and growth. This is my life’s work and it is enormously gratifying. I have adapted to changes in the field of psychology over the years, yet the heart of my work has remained my ability to establish a positive relationship with each patient.

Recently, a former long-term patient celebrated a milestone birthday. She called my office phone, the landline I have had for over 30 years, grateful to know I was still there. She wanted me to know that despite all odds—she was a newly sober alcoholic at the age of 35 when we first met—she had made it to the age of 70. When I returned her call to offer her my congratulations, she updated me about where she was living and her family members. Then she wistfully asked if I have FaceTime, so we could talk one more time, “in person.”



References

(2019, January 22). Bad Sex, Good Sex, Fiction That Makes Sense of How We Bone. The Cut Podcast. Podcast retrieved from
https://gimletmedia.com/shows/the-cut-on-tuesdays.

Essig, T., Turkle, S., Russell, G.I.. (2018, June 7). Sleepwalking Towards Artificial Intimacy: How Psychotherapy is Failing the Future. Forbes. Article retrieved from http://forbes.com.

McRobbie, L.R.. (2019, January 31). Apps can Put Therapy in the Palm of Your Hand. But What Happens When They Go Haywire?. The Boston Globe. Article retrieved from http://bostonglobe.com.

Newport, C. (2019, January 25). Steve Jobs Never Wanted Us to Use Our iPhones Like This. The New York Times. Article retrieved from http://nytimes.com.
 

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Bios
Maggie Mulqueen Maggie Mulqueen, PhD, is a psychologist in Brookline, MA, where she has maintained a private practice for over thirty years. In her clinical work she sees individuals and couples with a focus on deepening self-awareness and building relationships. She is the author of On Our Own Terms: Redefining Competence and Femininity (SUNY Press, 1992). Dr. Mulqueen has published essays in The Boston Globe, AARP Magazine, Psychotherapy Networker, Boston Parents Paper, Brain, Child Magazine and Wellesley/Weston Magazine. She was formerly on the faculty of Lesley University in the Counseling and Psychology Division. Dr. Mulqueen graduated from the University of Pennsylvania in 1984 where she received the Phi Delta Kappa award for Dissertation of the Year.