‘Screen-time transferential interference’ in encounters with patients

I cannot recall the last time that I had a good look at the cashier who was scan­ning my grocery purchases. I could not tell you what color eyes he (or she?) had or how he styled his hair. This isn’t for lack of an effort to recall, or a mani­festation of poor memory or absentmind­edness. Rather, I think that the situation reflects a larger cultural shift that has gained momentum since the beginning of the new century: that is, the effect of a preponderance of so-called screen time in our lives.

In that mundane scene in the grocery store, screen time encompasses the imper­sonal and mechanical act of swiping my debit card, entering my PIN, and impa­tiently waiting for the receipt to print. All the while, I stand awkwardly, eyes down­cast and fixed on the display of the card reader, ignoring the human being directly across from me.

Obsession with screens
Our engagement with screen time has grown to pandemic proportions, and television is no longer the main culprit. According to a Nielsen global consumer report,¹ in 2010 in the United States, people spent an average of 5 hours a day in front of the “boob tube.” Even if we take that statistic with a grain of salt, it still repre­sents only the most visible tip of the media iceberg. Smartphones, laptop and desktop monitors, portable gaming consoles, elec­tronic tablets, PIN pad displays, video bill­boards, and any number of other LED and LCD screen surfaces have infiltrated the landscape.

Whereas most recent epidemiologic studies have addressed the deleterious effects of so-called sit time (sedentary activ­ities with or without a screen) on physical health, I would like to address the deleteri­ous effect of screen time on mental health and relational connectedness and the rel­evance of that screen time to psychiatric practice.

The ‘techno-bubble of private space’
Almond,² in a humorous social com­mentary, “Connection Error,” conducted an impromptu experiment in which he attempted to connect spontaneously with strangers, especially those who had a smartphone, in Boston. His narrative navigates the gamut of human interac­tion, from tedious and boorish to comedic and absurd, noting that, conspicuously, “smartphone users have created a techno-bubble of private space” in which they are physically present but emotionally unavailable.

A chance encounter with a young pro­fessional led Almond to this conclusion:

It’s precisely the intrusive alienation of the “techno-bubble” that blunders into the modern patient-physician interaction in my clinical psychiatric practice in a busy outpatient clinic at a university medi­cal center. Specifically, the ever-glowing, ever-distracting computer monitor sit­ting between me and my patient, with its promise of digital information at my fin­gertips, serves more to distance me from my patient than to connect us in a mean­ingful, human way. Just as I can’t recall the countenance of the grocery-store cashier, I miss the delicate, information-laden, minute-to-minute social interaction with the patient because it competes with the electronic intruder.

What’s at risk when a computer screen is in the room?
Transference in the psychotherapeutic encounter is an established tenet of psycho­analytic theory. In “Basic theory of psycho­analysis,”³ Waelder defines transference as “not simply the attribution to new objects of characteristics of old ones but the attempt to re-establish and relive, with whatever object will permit it, an infantile situa­tion much longed for because it was once either greatly enjoyed or greatly missed.” This definition applies to the positive pole of transferential phenomena—and it is this position that is desired in a successful patient−physician encounter.

A patient’s warm and genial regard toward a provider secures trust, coop­eration, and faith in the healing process. Establishment of positive trans­ference toward the physician is essential to enhance the clinical encounter, regard­less of what early object (caring mother, omnipotent father) is being projected onto the physician.

Attunement. Research into infant obser­vation has revealed the critical role of caretaker responsiveness in the develop­ment of early infantile emotional regu­lation. Tronick et al⁴ demonstrated the importance of interactional reciprocity in the mother−child dyad.

In a series of experiments using the so-called still-face paradigm, Tronick et al⁴ saw that infants quickly fall into a state of despair and related negative affects when the mother assumes an unresponsive and detached still face. These episodes inten­tionally produce infant-mother emotional misattunement, which, although instantly damaging, can be successfully repaired through re-attunement by the mother. It is the primary caretaker’s ability to reconnect and repair that is paramount to the infant’s healthy psychological development.

This sentiment is echoed in Winnicott’s concept of the “good-enough” mother (or parent), formulated years earlier, in which failures in infant−caretaker attunement are inevitable and to be expected—as long as repair outcompetes deficiency.⁵

Divided attention: Patient or screen? Or both?
What we can understand by applying the ideas of transference and optimal attun­ement to the clinical encounter is how important uninterrupted face-to-face time with the patient is. Indeed, nonverbal com­munication from the patient, expressed though body language and facial articula­tion, is particularly salient to the practice of psychiatry. Information technology— especially the electronic health record—now encroaches on the time-honored central dyad of the patient-physician interaction by introducing a third entity into the tradi­tional encounter.

Clinical misattunement, as understood through the still-face paradigm, increases in proportion to a provider’s need to divide his (her) attention between the patient and the computer screen. And, as the degree of misattunement increases, positive transference is more difficult to establish and maintain. The quality of the clinical encounter then deteriorates, undermining the care of the patient and reducing physi­cian satisfaction.

Acknowledgment
Philip LeFevre, MD, Department of Neurology & Psychiatry, Saint Louis University, St. Louis, Missouri, provided inspiration and encouragement in the development of the manuscript.

Disclosure
Dr. Afanasevich reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

I cannot recall the last time that I had a good look at the cashier who was scan­ning my grocery purchases. I could not tell you what color eyes he (or she?) had or how he styled his hair. This isn’t for lack of an effort to recall, or a mani­festation of poor memory or absentmind­edness. Rather, I think that the situation reflects a larger cultural shift that has gained momentum since the beginning of the new century: that is, the effect of a preponderance of so-called screen time in our lives.

In that mundane scene in the grocery store, screen time encompasses the imper­sonal and mechanical act of swiping my debit card, entering my PIN, and impa­tiently waiting for the receipt to print. All the while, I stand awkwardly, eyes down­cast and fixed on the display of the card reader, ignoring the human being directly across from me.

Obsession with screens
Our engagement with screen time has grown to pandemic proportions, and television is no longer the main culprit. According to a Nielsen global consumer report,¹ in 2010 in the United States, people spent an average of 5 hours a day in front of the “boob tube.” Even if we take that statistic with a grain of salt, it still repre­sents only the most visible tip of the media iceberg. Smartphones, laptop and desktop monitors, portable gaming consoles, elec­tronic tablets, PIN pad displays, video bill­boards, and any number of other LED and LCD screen surfaces have infiltrated the landscape.

Whereas most recent epidemiologic studies have addressed the deleterious effects of so-called sit time (sedentary activ­ities with or without a screen) on physical health, I would like to address the deleteri­ous effect of screen time on mental health and relational connectedness and the rel­evance of that screen time to psychiatric practice.

The ‘techno-bubble of private space’
Almond,² in a humorous social com­mentary, “Connection Error,” conducted an impromptu experiment in which he attempted to connect spontaneously with strangers, especially those who had a smartphone, in Boston. His narrative navigates the gamut of human interac­tion, from tedious and boorish to comedic and absurd, noting that, conspicuously, “smartphone users have created a techno-bubble of private space” in which they are physically present but emotionally unavailable.

A chance encounter with a young pro­fessional led Almond to this conclusion:

It’s precisely the intrusive alienation of the “techno-bubble” that blunders into the modern patient-physician interaction in my clinical psychiatric practice in a busy outpatient clinic at a university medi­cal center. Specifically, the ever-glowing, ever-distracting computer monitor sit­ting between me and my patient, with its promise of digital information at my fin­gertips, serves more to distance me from my patient than to connect us in a mean­ingful, human way. Just as I can’t recall the countenance of the grocery-store cashier, I miss the delicate, information-laden, minute-to-minute social interaction with the patient because it competes with the electronic intruder.

What’s at risk when a computer screen is in the room?
Transference in the psychotherapeutic encounter is an established tenet of psycho­analytic theory. In “Basic theory of psycho­analysis,”³ Waelder defines transference as “not simply the attribution to new objects of characteristics of old ones but the attempt to re-establish and relive, with whatever object will permit it, an infantile situa­tion much longed for because it was once either greatly enjoyed or greatly missed.” This definition applies to the positive pole of transferential phenomena—and it is this position that is desired in a successful patient−physician encounter.

A patient’s warm and genial regard toward a provider secures trust, coop­eration, and faith in the healing process. Establishment of positive trans­ference toward the physician is essential to enhance the clinical encounter, regard­less of what early object (caring mother, omnipotent father) is being projected onto the physician.

Attunement. Research into infant obser­vation has revealed the critical role of caretaker responsiveness in the develop­ment of early infantile emotional regu­lation. Tronick et al⁴ demonstrated the importance of interactional reciprocity in the mother−child dyad.

In a series of experiments using the so-called still-face paradigm, Tronick et al⁴ saw that infants quickly fall into a state of despair and related negative affects when the mother assumes an unresponsive and detached still face. These episodes inten­tionally produce infant-mother emotional misattunement, which, although instantly damaging, can be successfully repaired through re-attunement by the mother. It is the primary caretaker’s ability to reconnect and repair that is paramount to the infant’s healthy psychological development.

This sentiment is echoed in Winnicott’s concept of the “good-enough” mother (or parent), formulated years earlier, in which failures in infant−caretaker attunement are inevitable and to be expected—as long as repair outcompetes deficiency.⁵

Divided attention: Patient or screen? Or both?
What we can understand by applying the ideas of transference and optimal attun­ement to the clinical encounter is how important uninterrupted face-to-face time with the patient is. Indeed, nonverbal com­munication from the patient, expressed though body language and facial articula­tion, is particularly salient to the practice of psychiatry. Information technology— especially the electronic health record—now encroaches on the time-honored central dyad of the patient-physician interaction by introducing a third entity into the tradi­tional encounter.

Clinical misattunement, as understood through the still-face paradigm, increases in proportion to a provider’s need to divide his (her) attention between the patient and the computer screen. And, as the degree of misattunement increases, positive transference is more difficult to establish and maintain. The quality of the clinical encounter then deteriorates, undermining the care of the patient and reducing physi­cian satisfaction.

Acknowledgment
Philip LeFevre, MD, Department of Neurology & Psychiatry, Saint Louis University, St. Louis, Missouri, provided inspiration and encouragement in the development of the manuscript.

Disclosure
Dr. Afanasevich reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

I cannot recall the last time that I had a good look at the cashier who was scan­ning my grocery purchases. I could not tell you what color eyes he (or she?) had or how he styled his hair. This isn’t for lack of an effort to recall, or a mani­festation of poor memory or absentmind­edness. Rather, I think that the situation reflects a larger cultural shift that has gained momentum since the beginning of the new century: that is, the effect of a preponderance of so-called screen time in our lives.

In that mundane scene in the grocery store, screen time encompasses the imper­sonal and mechanical act of swiping my debit card, entering my PIN, and impa­tiently waiting for the receipt to print. All the while, I stand awkwardly, eyes down­cast and fixed on the display of the card reader, ignoring the human being directly across from me.

Obsession with screens
Our engagement with screen time has grown to pandemic proportions, and television is no longer the main culprit. According to a Nielsen global consumer report,¹ in 2010 in the United States, people spent an average of 5 hours a day in front of the “boob tube.” Even if we take that statistic with a grain of salt, it still repre­sents only the most visible tip of the media iceberg. Smartphones, laptop and desktop monitors, portable gaming consoles, elec­tronic tablets, PIN pad displays, video bill­boards, and any number of other LED and LCD screen surfaces have infiltrated the landscape.

Whereas most recent epidemiologic studies have addressed the deleterious effects of so-called sit time (sedentary activ­ities with or without a screen) on physical health, I would like to address the deleteri­ous effect of screen time on mental health and relational connectedness and the rel­evance of that screen time to psychiatric practice.

The ‘techno-bubble of private space’
Almond,² in a humorous social com­mentary, “Connection Error,” conducted an impromptu experiment in which he attempted to connect spontaneously with strangers, especially those who had a smartphone, in Boston. His narrative navigates the gamut of human interac­tion, from tedious and boorish to comedic and absurd, noting that, conspicuously, “smartphone users have created a techno-bubble of private space” in which they are physically present but emotionally unavailable.

A chance encounter with a young pro­fessional led Almond to this conclusion:

It’s precisely the intrusive alienation of the “techno-bubble” that blunders into the modern patient-physician interaction in my clinical psychiatric practice in a busy outpatient clinic at a university medi­cal center. Specifically, the ever-glowing, ever-distracting computer monitor sit­ting between me and my patient, with its promise of digital information at my fin­gertips, serves more to distance me from my patient than to connect us in a mean­ingful, human way. Just as I can’t recall the countenance of the grocery-store cashier, I miss the delicate, information-laden, minute-to-minute social interaction with the patient because it competes with the electronic intruder.

What’s at risk when a computer screen is in the room?
Transference in the psychotherapeutic encounter is an established tenet of psycho­analytic theory. In “Basic theory of psycho­analysis,”³ Waelder defines transference as “not simply the attribution to new objects of characteristics of old ones but the attempt to re-establish and relive, with whatever object will permit it, an infantile situa­tion much longed for because it was once either greatly enjoyed or greatly missed.” This definition applies to the positive pole of transferential phenomena—and it is this position that is desired in a successful patient−physician encounter.

A patient’s warm and genial regard toward a provider secures trust, coop­eration, and faith in the healing process. Establishment of positive trans­ference toward the physician is essential to enhance the clinical encounter, regard­less of what early object (caring mother, omnipotent father) is being projected onto the physician.

Attunement. Research into infant obser­vation has revealed the critical role of caretaker responsiveness in the develop­ment of early infantile emotional regu­lation. Tronick et al⁴ demonstrated the importance of interactional reciprocity in the mother−child dyad.

In a series of experiments using the so-called still-face paradigm, Tronick et al⁴ saw that infants quickly fall into a state of despair and related negative affects when the mother assumes an unresponsive and detached still face. These episodes inten­tionally produce infant-mother emotional misattunement, which, although instantly damaging, can be successfully repaired through re-attunement by the mother. It is the primary caretaker’s ability to reconnect and repair that is paramount to the infant’s healthy psychological development.

This sentiment is echoed in Winnicott’s concept of the “good-enough” mother (or parent), formulated years earlier, in which failures in infant−caretaker attunement are inevitable and to be expected—as long as repair outcompetes deficiency.⁵

Divided attention: Patient or screen? Or both?
What we can understand by applying the ideas of transference and optimal attun­ement to the clinical encounter is how important uninterrupted face-to-face time with the patient is. Indeed, nonverbal com­munication from the patient, expressed though body language and facial articula­tion, is particularly salient to the practice of psychiatry. Information technology— especially the electronic health record—now encroaches on the time-honored central dyad of the patient-physician interaction by introducing a third entity into the tradi­tional encounter.

Clinical misattunement, as understood through the still-face paradigm, increases in proportion to a provider’s need to divide his (her) attention between the patient and the computer screen. And, as the degree of misattunement increases, positive transference is more difficult to establish and maintain. The quality of the clinical encounter then deteriorates, undermining the care of the patient and reducing physi­cian satisfaction.

Acknowledgment
Philip LeFevre, MD, Department of Neurology & Psychiatry, Saint Louis University, St. Louis, Missouri, provided inspiration and encouragement in the development of the manuscript.

Disclosure
Dr. Afanasevich reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.