Psychoanalysts who use social media must navigate unfamiliar and difficult terrain. Public electronic communications can breed intense transferences and exert pressure on professional boundaries. Analysts should be aware of the potential for conflicts, boundary issues, and tensions between public and clinical personae.
I will confine my remarks to Twitter, which has come to be used with some frequency by organizations such as the American Psychoanalytic Association @apsaafeed, the Division of Psychoanalysis of the American Psychological Association (APA Division 39), the New York State Psychological Association (NYSPA), by several analytic institutes, and by a growing number of clinicians in private practice. For those who don't already know, here is how it works: Anyone can open an account. Users write a short descriptive paragraph and pair it with a photo or avatar. Tweets are similar to e-mail except they are limited to 140 characters, and most importantly, they are not private; anyone who follows an account can view a user's messages. Tweets can be directed to a particular environment by using a “hashtag,” the designated symbol “#,” followed by the desired electronic location (for example, #psychoanalysis).
But that is just the nuts and bolts; it does not explain why analysts might want to use social media—especially since engaging in public interactions seems to contradict the private nature of our practice. Despite their apparent risks, the sites do have some benefits. They offer a way to reach many people very quickly, build networks, serve as potential sources of referrals, and they provide a means of promoting publications and boosting one's professional image. Of course, social media situations can also present challenges to the analyst's maintenance of a professional role and demeanor. What an analyst says and does potentially affects both individuals encountered on Twitter and patients treated in private practice. What works in one setting does not necessarily work in the other.
Traditional standards of practice do not delineate how the analyst should interact on Twitter. If we are trained to listen, and listen deeply, for remnants of what has gone on in the past, to tune into how its artifacts remain alive in the present, and to pay attention to whatever might be going on in the room at any given moment with a patient, that is certainly not how we engage on Twitter. Helping others to develop insight into their psychologies and come to a place of acceptance of all aspects of the self is often a jointly held goal in work with patients, and our interactions reflect this mutual expectation and clinical arrangement. But what must we do, for example, when approached for advice or counsel, or when confronted publicly with an electronic acquaintance's feelings via social networks?
It is important to establish rules of appropriate behavior for analysts and other clinicians who interact on Twitter or other similar outlets. Some questions I have had to consider: Can analysts opine about pop culture? Is it acceptable to be playful in a public forum? Do we seem cavalier if we discuss mental health issues at all, and does public discourse about weighty matters open up a Pandora's box of potential harm to patients and the public? What happens when people ask us for advice or help; how should we respond in a public forum? And how should we hear complaints? I will offer some guidelines, but first, a note about transferences that may arise when acquaintances interact via social media.
To define “transference,” I borrow from Willie Hoffer's 1956 article on “Transference and Transference Neurosis.”
The term transference refers to the generally agreed fact that people when entering into any form of object-relationship…transfer upon their objects those images which they encountered in the course of previous infantile experiences. The term transference, stressing an aspect of the influence our childhood has on our life as a whole, thus refers to those observations in which people in their contacts with objects, which may be real or imaginary, positive, negative, or ambivalent, transfer their memories of significant previous experiences and thus “change the reality” of their objects, invest them with qualities from the past.
On Twitter I am frequently invested with qualities from the past in ways Hoffer could never have envisioned in 1956. I am sometimes approached by people who are apparently in treatment with other mental health professionals, many of whom seek to play something out or push the envelope with me. For example, recently a woman tweeted in the middle of the night asking for advice about a troubled relationship. I suspected she was enacting with me a fantasy of having a 24/7 caregiver, a mother with ever-flowing milk. I did not answer (especially not in the middle of the night). But her request gave me pause.
Stephanie Newman Ph.D., is a faculty member at IPE, the author of Mad Men on the Couch: Analyzing the Minds of the Men and Women of the Hit TV Show, and co-editor of Money Talks: In Therapy, Society, and Life.
As I thought about how to respond, it seemed clear that my usual ways of comporting myself with patients did not seem to govern my interactions on Twitter. In the consulting room I listen in the here and now for the transference, past and present, and its derivatives as a way to understand unconscious fantasy and work towards increased insight into and acceptance of all parts of the self. But on Twitter I am at a loss. In this example described above, someone was communicating something to me, but I was not her analyst or therapist. I was not in a position to do clinical work with her. Nor am I able to be in constant contact with my followers on Twitter. When this woman attempted to get in touch, I wanted to set a respectful limit and show empathy, while remaining professional. But, all of that was easier said than done.
The challenge of dealing publicly with those who have not engaged my services but have displayed some need for me seems a millennial permutation of Hans Loewald's 1960 formulation, taken loosely, about patients using the object in a different way. Some might want something from me, even if I cannot give it to them or analyze their wishes. So, I had to deal with being a new object by crafting the persona of a psychoanalyst on Twitter—and if that were not difficult enough, I had to make it up as I went along.
In the example just given, I could see that the woman who wrote asking for relationship guidance was in emotional pain and needed to talk to someone. While I would normally have interpreted a late night phone call from a patient, I was not in a therapeutic relationship with this individual. At some point the following day, I tweeted that I could not give advice over the Internet and asked if she had a therapist. Not surprisingly, she did, and she noted that she had already made an appointment. There have been no more late night tweets or requests for advice from her.
As this vignette illustrates, it is sometimes difficult to know exactly how to respond when social media acquaintances communicate in ways that might be meaningful in treatment but might represent harmless interactions outside of the consulting room. One challenge of being a psychoanalyst on Twitter is to figure out how to retain a professional demeanor but not act intrusively or callously. In other words how to engage in an authentic manner without making interpretations or doing harm by hurting feelings, causing offense, or giving specific advice.
I have come up with the following guidelines for myself and other psychoanalysts and psychotherapists who use social media networks:
I do not tweet with my patients.
I do not discuss clinical issues in a public forum, nor do I offer advice on Twitter or any similar outlet; rather, I suggest making contact with a licensed mental health professional.
When people I encounter on Twitter ask personal questions, I do not give information about myself, my family, or my private life.
When this woman attempted to get in touch, I wanted to set a respectful limit and show empathy, while remaining professional. But, all of that was easier said than done.
I am careful never to criticize or mock those with emotional problems. While this sounds obvious, social media and snark go hand in hand; many who use social networks adopt irreverent personae, and may do so in good fun.
When composing a tweet (or writing for any publication, especially those read online), I ask myself: Would I be comfortable if a patient or a colleague read this?
The problem of how analysts should interact is not just limited to encounters on Twitter. It is hard to know what, if any, possible spillover effects might be experienced by actual patients whose analysts use social media.
In her seminal book, Writing about Patients, Judy Kantrowitz cautions that the most important thing for the analyst is to continually endeavor to protect the clinical situation. If publishing a vignette would compromise the treatment, then one is ethically prohibited from doing so. I use this guideline with respect to my clinical practice and use of social media. Seeking to minimize any potential deleterious effects, I have drawn and attempt to adhere to certain lines in the sand. As mentioned, I never tweet with patients or discuss any clinical matters on a public forum. I would not follow a patient or respond electronically if contacted via Twitter; rather, I would encourage the tweeter to bring all communications into the office where we can work to understand them.
As yet, I have not had any patients attempt to follow me on Twitter. I know this because followers are a matter of record. And while several patients have discussed in session things I have written for different publications, none has attempted to Tweet to me and none has mentioned anything on the surface or in derivative form about reading what I have put on Twitter—though I expect my personal comfort level and guidelines will continue to be challenged as new situations arise. When they do, I will act as I have always done: attempt to analyze and understand what it all means to the patient.
If only it could be as simple as it sounds.
As for what I Tweet about and how that comes across: My comments are largely confined to topics of general interest, such as teens' reliance on technology or the psychology of fictional characters. Sometimes I pass along news stories or articles of note. And, I do that in a light way, always using a respectful tone. I try to maintain the persona of a kind, well-intentioned, and empathic analyst who adheres to a professional demeanor and boundaries. I try to write as though I were giving a talk to other professionals or to persons in the community.
Given the tensions and difficulties I have discussed, it seems clear that many analysts and other mental health professionals will continue to shy away from social media avenues and will remain skeptical about how to best use them. It is not always easy or straightforward, but it can be done. Twitter can be a useful tool for those wishing to build a practice, expand referral networks, or promote academic and other kinds of writing. The trick is to figure out how to best navigate its murky waters.
I would like to thank Claudia Lament and Rita Clark for reading and providing helpful suggestions about the content and scope of this article.
Editor's Note: This article previously appeared in The Psychoanalytic Association of New York Bulletin and in the online edition of Psychology Today and was reprinted with permission and minor changes.