In my early years of private practice, I was anxious about being accessible to my patients in the event of an emergency. I structured my life so as to maximize my availability, keeping in frequent contact and responded to calls as quickly as possible.

The reward for my assiduity was a great many calls, most of which came from a small group of patients diagnosed with borderline or narcissistic character disorders. I soon came to understand why maintaining therapeutic boundaries was critical to the prevention of regression and to the growth of mature ego functions, and began to delay my response to calls intentionally unless it was likely that they might constitute the rare true emergency. Predictably, the volume of calls diminished sharply from that point onward.

Fixated at an immature level of ego development, borderline and narcissistic patients tend to lack a firm sense of identity, feel the need for immediate gratification, act impulsively, wish to merge yet fear true intimacy, and, thus, have a difficult time seeing others as existing outside of the context of their own wants, needs, and feelings.

Two important goals with such patients are the renouncement of a sense of entitlement and the building of a sense of completeness in which they can delay gratification and tolerate being alone yet form authentic, intimate, relationships. To these ends it is essential that these patients learn to understand the difference between a need and a desire. This is modeled and reinforced in the therapeutic frame.

The fact that we are seeing narcissistic patients with increasing frequency should not be surprising when one considers that our society as a whole has moved in a direction of increasing narcissism. Industrialization and upward mobility encourage each middle-class individual to acquire the material outer trappings of an aristocrat and to pursue image at the expense of substance. Society itself is becoming more "as if." Fragmentation of social, religious, and familial institutions and the focus on materialism conspire to diminish the sense of being a unique individual with a clear social role. Unknown and unloved, we seek an identity in our material possessions. This has been capitalized on and intensified by advertising and the electronic media, which encourage us to pursue the passive and immediate gratification of perceived needs and to embrace the illusion that fulfillment comes from without rather than within.

The ever present unreality with which most of us surround ourselves—the din of television, radio, portable music, video games, and the like—isolates the individual from the natural world and obliterates the inner voice of consciousness. It robs us of a sense of connection to the world and to ourselves. Is it this that drives us to create an ever more constant illusion of connectedness in the virtual space of the telephone and of the Internet?

The burgeoning use of cell phones, faxes, e-mail, their useful aspects notwithstanding, reinforces and legitimizes a perceived need for constant connection to others, while ironically, creating detachment. It fosters impulsivity and contributes to a vicious circle of crisis-driven interactions. It reduces the ability of the individual to achieve a healthy separation of himself or herself from the demands of others. It encourages us to see others as existing to fulfill our immediate demands, and so, to view the other as "object." Is this not pathological narcissism?

As therapists we, too, are subject to the seductive forces of these technologies. Much has been written lately concerning their impact on confidentiality, but this threat pales in comparison to a more subtle one. As the use of these devices becomes institutionalized and is perceived as the norm, what effect will this have on our concepts of normality and on our ability to model and to foster what has, up until now, been seen as normal? In an era when psychoanalytic theory and principles are lost upon the general public and even within our own circle, when boundaries are of less and less concern to the average person, how are we to justify and to maintain the key therapeutic stance upon which our success as therapists relies?

It is my opinion that we must be careful about how we use technologies in our work and in our lives. We cannot afford to embrace them uncritically or to use them indiscriminately. We must exercise appropriate restraint and caution, not for the oft-cited reason of confidentiality alone, but for the sake of keeping our patients and ourselves whole. 

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Dr. Dovberg is a psychiatrist who practices in Albany, N.Y.