Therapist Anonymity: Being a Blank Screen in a Touch Screen World

In “Recommendations to Physicians Practicing Psychoanalysis,” Freud cautioned against the temptation of bringing the psychoanalyst’s individuality and personal life into the analysis. Freud thought that self-disclosure “achieves nothing toward the uncovering of what is unconscious” and makes the patient “even more incapable of overcoming his deeper resistances.” His solution was that “the doctor should be opaque to his patients and, like a mirror, should show them nothing but what is shown to him.” This guidance, encapsulated as Therapist Anonymity, joined Therapist Neutrality and Abstinence as cornerstones of psychodynamic psychotherapy. The aspirational goal of the therapist as a “blank screen” was born. The place of Therapist Anonymity in modern psychotherapy, however, is less certain.

First, we must acknowledge that Freud did not always practice what he preached. There are numerous examples in Freud’s own writing of his interacting freely and personally with his analysands. As his reputation grew, patients sought him because of what they already knew about him. They did not come to see a blank screen; they came to see the famous Dr. Freud. Nevertheless, Freud’s patients developed pronounced transferences. Since Freud’s time, theorists have wondered if transference might not inevitably develop within the therapy relationship no matter what the patient knows about the therapist.

Second, complete Therapist Anonymity has always been a bit of a chimera. Patients learn about their therapist with each interaction. The decoration of the office, the books on the shelf, and the state of the therapist’s desk all give indications to the therapist’s habits and interests. The plaques and awards on the wall tell of the therapist’s training and expertise. The questions that are asked, or not asked, give indications as to what the therapist considers important.

Third, Freudian concepts are no longer the only game in town. Other therapy approaches utilize the interpersonal interactions and real relationship between therapist and patient. Interpersonal and relational analysts discuss what the patient knows or believes about the therapist. Rather than consider these as adulterants to the therapy, they are valued as vital to the therapy process. Therapies that do not emphasize the development and understanding of transference, such as cognitive-behavioral therapy, also downplay the significance of anonymity.

Further challenges arise in less-populated communities and may increase the likelihood of encountering a patient outside of the office. These communities exist in smaller towns but can also arise within larger metropolitan areas. Health care systems might segregate populations (such as the military) by permitting members to see a restricted number of health care professionals. Individuals may seek out psychiatrists from their religious, ethnic, or cultural backgrounds, and therapists specializing in a specific population may find themselves in a shrinking pool of social and professional interactions. The children of the psychiatrist and the patient may interact at school or other activities such as sports or scouts. That indirect contact can lead to direct extra-therapeutic contact as both patient and psychiatrist support their children’s activities.

Psychiatrists treating medical professionals may find themselves working in the same medical settings or serving on committees with patients. The psychiatrist’s spouse may unknowingly interact with patients or with patients’ spouses. Patients may not initially associate the spouse with their psychiatrist, especially if they do not share a last name, but in smaller communities, these relationships will become evident.

The internet and social media present the greatest modern challenge to Therapist Anonymity. Patients can easily check PubMed for their therapist’s academic output.

They may go to university websites and read about their therapist’s training and clinical or research interests. If therapists are not careful with their social media settings, patients can obtain a frank glimpse of the therapist’s personal life.

In light of these challenges, several recommendations can be made:

• Psychiatrists should always discuss the potential for out-of-office encounters with patients. They can preemptively discuss appropriate interactions in those settings.

• When a patient approaches the psychiatrist outside of the office, any ensuing conversations should be focused exclusively on the current surroundings. Therapeutic material should never be discussed.

• Encounters outside the office should be discussed in therapy in a neutral fashion. The therapist can explore what was said, what was observed, what the patient felt, what the patient imagined, and what they might do differently the next time it happens.

• Psychiatrists should assiduously guard their social media presence. They should repeatedly check their privacy settings and consider the information they are putting on the internet.

Therapist Anonymity is never complete, and out-of-office contacts cannot be totally eliminated, but foresight and preparation can ensure that beneficial psychotherapy continues in the modern era. ■