By Jack Drescher, MD
Today's technologies make it likely that patients know more about their therapists than questionable taste in office furnishings or the presence of an occasional bad hair day. For many, googling a therapist before an initial appointment is simply considered an example of appropriate due dilgence. Patients can easily find out if and where a therapist owns a home, to which charities or political parties a therapist has contributed, and names of a therapist's family members. Publications? Academic affiliations? Censure by professional organizations or licensing bodies? All searchable. And now, with Electronic Medical Records on the horizon, what and how psychotherapists think about their patients will increasingly become collaboratively accessible.
Good-bye blank screen.
Television and films frequently portrayed the stereotypical psychotherapist who, having listened to a patient's long emotional monologue, responds, "Sorry, our time is up!" What the doctor was thinking or feeling during that time remains an elusive mystery.
That stereotype is based upon a kernel of truth. The role of silent, non-responsive therapist was created by Sigmund Freud, who in a series of "Papers on Technique" published a century ago, advised, "The doctor should be opaque to his patients and, like a mirror, should show them nothing but what is shown to him".
Were therapists ever really a "blank screen?" Probably not. An early critic of the model was Sandor Ferenczi, a close Freud follower to whom we can attribute our field's present understanding that therapist opacity is an idealized, rarely achievable and often undesirable clinical attitude. As a result of Ferenczi's seminal contributions, Freud's "blank screen" approach has been greatly modified in the modern psychotherapeutic world.
Yet vestiges of the blank screen model still persist as noted in a recently published commentary from the Psychopathology Committee of the Group for the Advancement of Psychiatry (GAP - a group for which I am honored to serve as the current President). The Psychiatric Note in the Era of Electronic Communication was published in the April issue of the Journal of Nervous and Mental Diseases. There the authors address the growing use of electronic medical records (EMR) and the likelihood that these new systems will allow patients both increased access and opportunity to see their own records.
What is most significant—and with important clinical consequence—is that with record-keeping system requiring greater transparency patients will be more likely to find out what their doctors think of them. The GAP Committee thinks it is better for patients to find out this information from the therapist rather than from other sources and uses clinical vignettes to illustrate how this might work.
Dr. A, for example, is treating Mr. J for depression and "Narcissistic Personality Disorder." However, Dr. A had never told Mr. J about the personality diagnosis and "The EMR forced Dr. A to reconsider his practice of avoiding discussion of certain issues."
Why would Dr. A avoid discussing issues? Some psychotherapists do not routinely reveal diagnostic thinking to patients and some may eschew the use of diagnoses at all (except for the ubiquitous, non-specific "Generalized Anxiety Disorder" as some diagnosis is required for insurance reimbursement.) In Dr. A's practice, he would "document diagnoses of personality disorders in the unshared record, but did not disclose these diagnoses with patients or other providers."
Why not? Concerns about stigma seem paramount. After deciding to discuss the personality disorder diagnosis with Mr J, who "was first aghast at the label," their discussion ultimately facilitated greater awareness about how Mr J's personality style affected his relationships." Nevertheless, "Mr. J insisted that the information related to his interpersonal functioning be in a private section of his record accessible only to himself and Dr. A."
Stigma about mental disorders is, of course, an ongoing concern. Yet so are traditional paternalistic and infantilizing attitudes that rightly or wrongly assume patients cannot deal with their therapists' hidden assessments. While some may bemoan the interference of newer technologies in upsetting traditional models of psychotherapy (again, think of all those patients now googling their therapists), as in the case of Dr. A and Mr. J, adapting to the new transparency and creating more openness between therapist and patient can have a salutary effect. After all, information is power and patient empowerment is a goal in every treatment.
About the author:
Jack Drescher, MD, is a Training and Supervising Analyst at the William Alanson White Institute in NYC. He is a Clinical Associate Professor of Psychiatry at New York Medical College and a member of the DSM-5 Workgroup on Sexual and Gender Identity Disorders. The author of Psychoanalytic Therapy and the Gay Man, he has written numerous scholarly articles and book chapters and edited a score of books dealing with gender and sexuality.
© 2011 Jack Drescher, All Rights Reserved