Is Your Therapy Practice Ready for the Digital Age?

“Anything that is in the world when you’re born is normal and ordinary and is just a natural part of the way the world works. Anything that’s invented between when you’re fifteen and thirty-five is new and exciting and revolutionary and you can probably get a career in it. Anything invented after you’re thirty-five is against the natural order of things.” – Douglas Adams, The Salmon of Doubt (2005)

A few months ago a fellow therapist with almost thirty years of clinical experience, let’s call her Margo, approached me for advice about a new client, an attorney in his late twenties that we’ll call Edward. Margo told me that in the middle of their second session—in the middle of a sentence, in fact—Edward abruptly stopped to read and then answer a text message. Margo sat quietly when this happened, expecting an apology or at least an acknowledgment of the interruption just as soon as Edward hit the send button. Instead, he simply picked up exactly where he’d left off, as if there’d been no interruption. Then, a few moments later, his phone buzzed and he once again paused to read and respond. This time, before Edward could resume with his monologue, Margo suggested that they set some boundaries about the ways in which the two of them were going to spend their time in therapy, with one of those boundaries being that Edward would need to turn off his phone. Edward shocked her by saying flat out that he neither could nor would, as his 3 pm session was in the middle of his workday and he was unwilling to abandon his job during this time frame. Then he said that Margo seemed to be a little bit out of touch with technology and the modern world, and if she couldn’t adjust, then, as much as he liked her, he might need to find a younger, more tech-savvy therapist. Ouch!

In part, the divide between Margo and Edward stems from the fact that Edward is a digital native (i.e., someone born after 1985 into an Internet-enabled world), while Margo, in her late fifties, is a digital immigrant (i.e., someone born prior to 1985 and the onset of the digital revolution). Essentially, Edward was born into a world of high-speed digital connections, where face-to-device interactions are as normal and as meaningful as face-to-face interactions. As such, he innately understands and utilizes both in-person and digital communications, moving fluidly between the real and virtual worlds as a way to stay constantly connected. Margo, on the other hand, has never been on Twitter, has only used Facebook as a form of scrapbooking, and thinks Instagram is probably some kind of new service provided by Western Union.

Needless to say, this tech-driven generation gap badly undermined Margo and Edward’s therapeutic alliance. Put simply, Margo did not acknowledge or even recognize the vast differences in the ways that her generation and Edward’s generation utilize technology. Nor did she recognize or understand that for Edward’s generation there is little to no difference between digital and in-person interactions, or that for Edward the two venues are equally important. As a result, despite Margo’s extensive knowledge and clinical experience, her ability to help Edward was stifled.

Of course, it’s not just client hyperconnectivity issues that sometimes baffle modern therapists. Equally puzzling concerns arise in all sorts of tech-driven arenas. Recognizing this, I want to present a few very brief therapeutic scenarios showcasing the tech-related problems most commonly encountered by digital-age therapists. My hope is to at least begin the discussion about how we, as therapists, can best handle these situations if and when they arise.

Parent-Child Online Issues

“Yesterday my twelve-year-old son Quentin sent me a text, wanting to know what we were having for dinner. This is pretty normal for him. In fact, he seems to prefer texting to talking, and most of the time I’m okay with that because I know that’s how kids communicate. But this time it really bothered me because while I was in the kitchen cooking dinner he was fifteen feet away from me, watching TV and playing on his iPhone. He could literally see me! What is wrong with him that he couldn’t turn his head and actually talk to me? Anyway, his text put me over the edge. I got so mad that I took away his phone and his laptop—I e-grounded him, I guess—for a week. Did I overreact?” – Helen, age thirty-nine

In today’s world, young people are hooked into their digital devices almost constantly. One 2009 study found that children between the ages of eight and eighteen spend 11.5 hours per day engaging with and through technology (Kaiser Family Foundation, 2010). Since most kids are awake for only fifteen or sixteen hours per day, somewhere between 71 and 76 percent of their waking hours involve some form of digital interaction. And, as any parent of the average three-year-old can attest, this nonstop tech-fest begins far earlier than this particular study’s low-end cutoff age of eight.

A more recent study, this one conducted in 2011, further illustrates young people’s infatuation with technology, finding that kids aged twelve to seventeen send an average of sixty texts per day, up from fifty in 2009 (Lenhart, 2012). This study also found that kids aged fourteen to seventeen are the most frequent texters, whipping off nearly one hundred texts per day, up from sixty in 2009. Most tellingly, the study found that texting is now the primary mode of communication between teens and their friends and family, far surpassing phone calls, e-mails, and even face-to-face interactions.

Pornography

“A few days ago I was stressed out and I accidently left my laptop at work. That night, after the kids had gone to bed, I needed to send a few emails, so I went into my fourteen-year-old son’s room and grabbed his tablet off the nightstand. I really wish I hadn’t, though, because what I found was porn city. Yes, I know that when I was his age I had a few dirty magazines, so I’m not a total prude about this, and I’m not trying to bury my head in the sand about what teenaged boys do. But this was a lot of porn, and some of it was nasty. I haven’t said anything to him or his mother, and I’m not even sure that I should. I mean, is this normal behavior?” – Robert, age forty-two

Reliable statistics about kids and porn use are few and far between, but it’s clear that in today’s world many users are adolescent and sometimes even preadolescent boys. Girls also use porn, but in general boys seem to be far more interested, likely because males in general are more visually stimulated, whereas females tend to require some sort of emotional context before becoming aroused (Ogas & Gaddam, 2012). For the most part, there are two primary questions being asked about boys and pornography: How many boys are looking at porn and how is porn affecting their development?

The first question, about the number of boys using porn, is relatively easy to answer. All of them! Consider that when Canadian researcher Simon Lajeunesse tried to study the effects of porn on young males, he couldn’t because he wasn’t able to find any potential test subjects who weren’t already porn users (Liew, 2009). Thus, there was no control group to make comparisons with. Yes, Lajeunesse was looking for college kids who hadn’t used porn, and there are probably a few younger boys out there who’ve not yet typed “sex” or “nude” into a search engine, but it’s clear that the vast majority of young males are interested in and looking at porn at least occasionally.

The second question about the effects of porn use is much more difficult to answer because there just isn’t any validated research on this topic. After all, subjecting underage kids to pornography just to see how they react is not only unethical, it’s illegal. This means the only scientific evidence we can realistically hope for is after-the-fact surveys asking adults about childhood porn use and its effects. And even that research is down the road, so to speak, because the Internet porn explosion in its current form—mostly free, streamed at high speed, and interactive in nature—is such a new phenomenon, only taking off in earnest around 2008.

Other Online Dangers

“Yesterday, my fifteen-year-old daughter came home in tears because some girls at her school were posting mean comments about her on Facebook. She screamed that she hates her life, and she wants to move to another town where the kids aren’t so mean. And this isn’t the first online incident for her. What scares me the most, though, is that she will meet some predator online and that person will harm her in some very serious way. What can I do to keep my daughter safe from all of these online dangers without her feeling like I’m spying on her or taking away her freedom?” –Patricia, age forty-six

Kids face a plethora of issues in the online world, just as they do in the real world. The most common concerns—in addition to young people’s obsession with tech and their easy access to pornography—are as follows:

Cyberbullying

This is the deliberate, repeated, and hostile use of digital technology to harm other people. This new form of childhood torture is nearly always perpetrated by other kids via text or social media, which makes it very hard to monitor and police.

Sexting

This is the transmission of sexualized imagery via smartphone. Now that most phones have built-in digital cameras, it is incredibly easy for a kid to impulsively take a provocative selfie and send it to a boyfriend, girlfriend or even a complete stranger. Unfortunately, once that image is sent, the “model” loses all control over it. The recipient may keep it private, forward it to others or post it online for public viewing. For many teens, sexted images are redefining what it means to have a bad breakup, as a resentful former boyfriend or girlfriend can send or post an ex’s nude pics pretty much anywhere, anytime, without reprisal.

Social Media Issues

Social media platforms are not games and they are not irrelevant in a child’s life. From a clinical standpoint they can actually be viewed as an extension of the self, with social media wounds and losses affecting self-esteem just as if they’d occurred IRL (in real life). Many children view the number of friends or followers they have on social media sites as a status symbol, and they sometimes tie their self-worth to the ways in which their adorable selfies and lovingly constructed, angst-filled posts are responded to or ignored. Yes, the emotions associated with social media often seem silly to digital immigrants, but for digital natives these online interactions are every bit as real and meaningful as in-person interactions.

Stranger Danger

In reality, the vast majority of online interactions are benign, just as the vast majority of real world interactions are benign. That being said, there are at least a few unsavory people lurking in the digital shadows. Usually, exposure to online predators occurs through social media or chat forums designed for and/or heavily frequented by young people, including Facebook, Skout, Chatroulette, Omegle, Tumblr, Snapchat, and Instagram, among others. And new venues for this behavior pop up constantly—every time kids decide that some other site or app is the hot place to be.

Adult Online Issues

“Last week, a Facebook friend posted a short video that he shot, without my knowledge, when I’d had too much to drink and was dancing around in my underwear at a party. This wouldn’t have been a problem except he also tagged the video with my name, which meant that my mom, who follows my Facebook page, was able to view it. Needless to say, she was not happy to see her son prancing around in his Jockey shorts. Plus, I know that at least a few people from my work also saw the video. I asked the person who posted it to remove it, which he did, and then I unfriended him, but the damage is done.” –Luis, age twenty-three

Luis is hardly the first intelligent adult to be victimized by an inappropriate post. Sometimes people even victimize themselves, knowingly and intentionally posting pictures that show them engaged in inappropriate behavior, little realizing that employers and schools often check social media pages as a way to evaluate applicants and/or to make sure their current employees and students are behaving. There are also people who post about every little detail of their romantic and sexual relationships, only to later see those posts create problems.

Falling in Love Online

“I’ve been married for five years, and gave birth to our son, Diego, eighteen months ago. After Diego was born, I quit my job so I could stay home as a full-time mom. Initially, I started going online as a way to entertain myself when Diego went down for his afternoon nap. I would chat with my friends from school that I didn’t get to see anymore, and I’d post funny sayings and photos that I found. Then one day I got an IM from an old boyfriend. Before I knew it, we were chatting online all the time, and I realized that I still have feelings for him. Now I feel like I’m in love with him and also with my husband, and that’s more than I can handle because I don’t want to lose either one. So far, my flirting with “the other man” is only online, but I’m worried he might suggest an IRL meeting. I really don’t know how I’ll respond if he wants to meet in person.” – Amy, age twenty-seven

If you’re struggling to understand how easy it is to fall for someone you’ve never met in person, consider the case of Manti Te’o. In 2012, Te’o was a well-known football star at Notre Dame. By all accounts he was and still is an incredibly intelligent, thoughtful, and responsible human being. While he was in college, he met a young woman on social media and fell deeply in love with her, despite their never meeting IRL. As it turns out, the “woman” was in reality a disturbed young man who was merely posing as an attractive female in the digital universe. But Te’o had fallen so hard and so fast that even after telltale signs of the deception began to surface he held tightly to the version of reality that meant so much to him. Eventually, of course, the ruse became public knowledge and he was forced to deal with the real-world truth, but until that point his entirely digital romantic relationship was every bit as heartfelt and meaningful to him as one undertaken with the girl next door. And it had to be grieved the same as an IRL broken heart.

Online Boundaries in Existing Relationships

“My girlfriend is big into social media, and so am I. So far we’ve had totally separate accounts, and that’s fine by me. I think we should each have some privacy. She can see my Facebook page and read my Twitter feed, but I don’t want her to have total access to my IMs, emails, texts, browser history, apps, and all the other stuff I do online. She disagrees. She thinks that because we’ve been dating for a while and we’re getting pretty serious—even talking about getting engaged—that we (meaning she) should have total access. She seems to think I’m keeping secrets from her if I don’t tell her what all of my passwords are. This seems crazy to me. Honesty is one thing, but a total lack of privacy is quite another. Am I being unreasonable?” –Marc, age twenty-six

One of the most common relationship bugaboos in the modern world is too much versus too little access to another person’s digital accounts. Sometimes one partner will threaten the other with a breakup if he or she doesn’t get the desired online access. Nevertheless, for some couples this online open door policy is actually preferred. When there is a difference of opinion, of course, this can be a difficult tightrope for some couples to walk.

Addiction

“After I graduated from college I got a great job in a major city several hundred miles from where I grew up. And I did well, too. I got a quick promotion and I even bought a condo. But I didn’t know anyone in my new city and I’ve never been good at making new friends. I guess I’ve just never felt comfortable in my own skin. To stay busy, I started going home after work and going online, looking at porn and playing around with hookup apps on my smartphone. Before long, I’d created this entirely different life that wasn’t real at all, spending five or six hours a night and sometimes even more than that looking at porn and having sex with strangers. I started losing sleep, my work slipped, and eventually I got in trouble at the office because I was looking at porn and playing around on hookup apps during work hours. I’ve tried to stop a bunch of times, and sometimes I’ve even managed it for a day or two, but then I’m right back at it. I’m scared. It seems like porn and anonymous hookups have taken over my life. – Max, age twenty-six

The deeper one looks at digital technology, the more obvious it is that anyone seeking pleasurable (and therefore potentially addictive) content and activities can find an unending supply online. The most common tech-driven addictions include:

Compulsive Spending

Compulsive spending—also called oniomania, shopping addiction, and compulsive buying disorder—occurs when people spend obsessively despite the damage this does to their finances and even their relationships. Digital technology, offering 24/7 access to goods and services, aids and abets them in this endeavor.

Digital and Online Gaming Addiction

This is the extreme use of computer and video games. Typically, gaming addicts play multiple hours daily, neglecting sleep, personal hygiene, diet, exercise, friendships, hobbies, school, work, and more.

Gambling Addiction

Also called compulsive gambling, gambling addiction is an uncontrollable urge to gamble despite profound, directly related negative consequences and a desire to quit. Typically, gambling addicts will play whatever game is available, though their preference is fast-paced games like video poker, slots, blackjack, and roulette, where rounds end quickly and there is an immediate opportunity to play again. Digital technology offers these games in abundance.

Romantic/Love/Intimacy Obsession

This is the compulsive search for romantic attachment. Dating sites, text and video chat rooms, hookup apps, and even social media sites can fan the flames of these unhealthy, obsessive relationships.

Sex/Porn Addiction

Also known as hypersexuality and sexual compulsivity, sex addiction is a dysfunctional, maladaptive preoccupation with sexual fantasy and behaviors. Online porn addiction, with or without masturbation, is now the most common form of sexual addiction. That said, sex addicts who prefer in-person encounters are equally vulnerable, abusing dating sites and apps, hookup sites and apps, video chat, sexting, and others.

Social Media Obsession

This is the quest to have the most friends or followers on sites/apps like Facebook and Twitter, to have one’s posts and tweets responded to in positive ways, and to “look good” through an endless series of narcissistic posts. Social media addicts often choose to bypass real world relationships, recreation, and social engagement for their online life, and their moods can become dependent on whether they have gained or lost any online followers/friends that day.

Moving Forward: Giving Advice

When dealing with parent-child issues, the primary fear seems to be that digital devices are evolving a generation of sad, pale, narcissistic creatures who can’t make eye contact and fear in-the-flesh interactions. In reality, this scenario isn’t in any way the norm for today’s kids. Yes, some of them do struggle with problems that arise in conjunction with digital devices, but most do not. And those who do struggle are usually the kids who are already vulnerable to various life problems—mood disorders, social anxiety, attachment deficits, addictions—courtesy of genetics and/or difficult early-life circumstances. In other words, these are the kids who tend to struggle with life, regardless of the technological age in which they live.

To be honest, advising parents about the online safety of their children is no easy task. For starters, there is a fine line between “loving parent” and “overprotective nut-job,” and that line varies in each unique parent-child relationship. Confounding matters further is the fact that the line doesn’t even stay consistent within a particular parent-child dynamic, because kids naturally need and desire increased autonomy as they mature. Plus, parental fears tend to be at least slightly overblown, as the online world is typically no more or less dangerous than the real world.

Nevertheless, parents naturally want to do everything they possibly can to protect their progeny. Sometimes parents think the best way to protect their children is to keep them offline altogether. This does not work! Even if parents take away a child’s laptop, smartphone, and other digital devices, the child can access the Internet at school, at the library, on friends’ devices, and on devices that he or she purchases and uses in secret. And should parents really attempt to take kids away from their age group’s top social venue? A better option, as is the case with almost any aspect of the parent-child relationship, is to instigate a series of honest, nonjudgmental, open-ended conversations. If necessary, this ongoing discussion can be supplemented with the installation of filtering and accountability software on the child’s digital devices (Weiss, 2015).

Dealing with adults’ tech-driven issues tends to be similar in most respects. For starters, open and honest dialogue in therapy and also with friends and loved ones about problems with digital devices is the best course of action. That being said, therapists need to be on the lookout for certain issues, in particular tech-driven addictions, as most clients are unlikely to willingly discuss the problems. It is important to understand that even though digital technology can become incredibly problematic for some adults—primarily those who are already predisposed to things like isolation, compulsivity, and addiction—most adults do not experience long-term problems simply because they occasionally play with emotionally arousing technologies, just as most adults who drink alcohol don’t become alcoholics. In cases where tech issues do seem to be out of control and causing long-term problems, therapists can suggest that clients install filtering and accountability software (Weiss, 2015).

Moving Forward: Therapists and Constant Learning

As therapists, a basic requirement of our job is that we gain cultural competency and insight into the upbringing and background of our client populations. If we don’t fully understand a client’s culture and belief system, we can’t fully trust our responses to his or her experience. And to our credit, most clinicians understand that the best client outcomes occur only after we’ve gained insight into the world of the individual or people we are treating, regardless of whether our client is a tech-driven, twenty-seven-year-old attorney who can’t put down his smartphone, a nineteen-year-old first-generation child of East-Asian immigrants, or an eight-seven-year-old alcoholic grandmother from Appalachia. Without cultural insight, or without at least acknowledging that there are cultural arenas in which our client has more knowledge and experience than we do, we risk unintentionally offending or alienating that person, thereby eroding our hard-won therapeutic alliance. Even worse, we might suggest actions based on our own background, values, and life-experience that are counterproductive or even damaging.

In today’s therapeutic milieu, the most commonly encountered “foreign” culture is the digital universe. As Internet-age therapists we need to understand—in fact, we are obligated to understand—that many of our clients were born into this world, with its unique and very specific expectations, rules, taboos, and endemic problems. We must further understand that this world is actually comprised of hundreds of separate subcultures, each with its own distinct code of conduct. In other words, things that can be posted on Twitter without repercussion may cause hurt feelings on Facebook, or a photo posted on social media may be perfectly fine to repost or retweet, while a photo sent as a text message attachment is probably supposed to stay private.

The point I’m trying to make is that as therapists we’d all better learn about new technologies, and probably even test them out, because pretty soon we’re going to encounter clients who are using them. In other words, it is vital, no matter how we personally feel about digital life, that we familiarize ourselves with new technologies—what they are, how they are used, how they are misused, the upside, the downside—because many of our clients, especially our younger clients, are engaging with these technologies on an almost constant basis. And when they come to see us with their digital age problems, we’d best know what they’re talking about. If not, we do them and ourselves a tremendous disservice.

References

Adams, D. (2005). The salmon of doubt: Hitchhiking the galaxy one last time. New York, NY: Del Rey.

Kaiser Family Foundation. (2010). Generation M2: Media in the lives of eight- to eighteen-year-olds. Retrieved from https://kaiserfamilyfoundation.files.wordpress.com/2013/01/8010.pdf

Lenhart, A. (2012). Teens, smartphones & texting. Retrieved from http://www.pewinternet.org/2012/03/19/teens-smartphones-texting/

Liew, J. (2009). All men watch porn, scientists find. The Telegraph. Retrieved from http://www.telegraph.co.uk/women/sex/6709646/All-men-watch-porn-scientists-find.html

Ogas, O., & Gaddam, S. (2012). A billion wicked thoughts: What the world’s largest experiment reveals about human desire. New York, NY: Plume.

Weiss, R. (2015). Filtering and accountability softwares for use in sex addiction recovery. Retrieved from http://www.robertweissmsw.com/resources/filtering-and-accountability-softwares-for-use-in-sex-addiction-recovery/

The Power of Families to Influence Addiction Recovery: An Interview with Robert J. Meyers, PhD

Reflections of an Addiction Psychiatrist