Case Study 02 — Chapter 39: Technology, Social Media...

Amara: What Presence Costs

Context

Amara is midway through her first MSW year. The Francis case is ongoing. Bernard's OT referral was followed through. The peer group functions as a legitimate professional learning community now, with a rotating concerns-advocate role she proposed and Marcus endorsed. Supervision has deepened since the agentic-state conversation — Amara brings genuine uncertainty now, not polished narrative.

There are twelve clients on Amara's caseload (supervised). Three are adolescents. The oldest is seventeen. The chapter's content arrives, as the best clinical material does, as an explanation for something Amara has already been observing without quite having the framework for it.

The Clinical Observation

Her adolescent clients are different from the adults.

This is obvious in some respects — developmental stage, presenting concerns, the texture of resistance. But there is something else that Amara has been trying to name for months. A quality of attention. Not inattention in the traditional clinical sense — the adults can be unfocused too. This is something more specific: a difficulty with the experience of having nowhere particular to be. A kind of restlessness with unstructured internal space.

Sixteen-year-old Destiny, presenting with mild anxiety and social withdrawal, describes it clearly in their seventh session: "It's not that I'm bored. It's more like — if I'm not watching something or doing something on my phone, I feel like I should be. Like I'm missing something."

Amara notes the word should. The absence of stimulation has become a normative violation — a state that triggers anxiety, not rest. Destiny describes checking TikTok an estimated three hundred times per day. Not for specific content. For the possibility that something is happening.

The chapter's variable-ratio reinforcement framing snaps into place. The three hundred checks are not information-seeking. They are the behavior produced by an unpredictable reinforcement schedule that has become habitual enough to feel like a baseline need.

The Research Conversation

In supervision, Amara brings the Haidt/Twenge versus Orben/Przybylski debate directly. Marcus listens through both positions.

"What do you take from the contested evidence?" he asks.

"That we can't establish causality from the correlational studies," Amara says. "But that doesn't mean the clinical observation is wrong. Destiny's anxiety has a specific content — FOMO, social comparison, the sense that everyone else's life is more interesting. The mechanism tracks even if the population-level effect size is contested."

"What do you do clinically when the evidence is contested but the presenting mechanism is clear?"

Amara has thought about this. "I treat the presenting mechanism with the best available tools. I don't wait for randomized controlled trials to confirm what the client is sitting in front of me describing."

Marcus: "That's a reasonable clinical posture. What does treatment look like?"

This is the question Amara has been working on. For adolescent anxiety generally, CBT is well-supported. But for anxiety that is substantially produced and maintained by a digital environment — one that the client will return to the moment they leave the session — the treatment focus needs to include the environmental design, not just the cognitive patterns within it.

Amara develops a three-component approach for Destiny and the other adolescent clients:

Psychoeducation about the attention economy — age-appropriate explanation of variable-ratio reinforcement, the business model of social media, the intentional design of engagement features. Not to produce outrage, but to produce agency: You are not failing at self-control. You are being designed toward a behavior that serves someone else's revenue model.
Environmental design, not willpower — phone out of the bedroom at night (negotiated with the parents; Destiny's initial resistance was significant); notification management; specific designated phone-free times. The chapter's spatial and temporal containment principles translated directly.
Behavioral activation toward non-digital sources of the underlying needs — Destiny's underlying need is for connection and relevance. The three-hundred-daily-checks are a substitute. What are the non-digital activities that have historically produced genuine connection and a sense of mattering? Destiny, after some prompting, identifies: baking with her grandmother, the art class she dropped in ninth grade, a childhood friend she stopped seeing because their friend groups diverged.

The psychoeducation piece produces something Amara did not expect. Destiny asks: "Who invented the infinite scroll?"

Amara: "A man named Aza Raskin. He invented it. Later he publicly said he regretted it."

Destiny: "He regrets it. And I can't stop using it."

A long pause. Then: "That makes me kind of angry."

Amara: "Good. What do you want to do with that?"

The social comparison component of Destiny's presenting concerns is specific and worth examining in clinical detail.

Destiny follows approximately four hundred accounts on Instagram. Amara does the category exercise from Exercise 39.4: genuine connection, aspirational, informational, habitual, negative comparison.

Of four hundred follows: - Genuine connection: 23 (friends, family) - Aspirational: 47 (fashion, fitness, "aesthetic" accounts) - Informational: 8 (art, one science account) - Habitual: 271 (accounts accumulated without intention) - Negative comparison: 51 (accounts Destiny identified as reliably producing inadequacy, envy, or the feeling of being "behind")

The negative comparison category, when Amara asks Destiny to look at it, is dominated by a specific type: peers slightly older than Destiny who appear to have their lives together. Not celebrities — relatables. The aspirational gap is optimized for maximum impact because it is plausible. This person is seventeen too. She looks like that. Her life looks like that. Why don't I look like that?

Amara: "What happens when you look at these?"

Destiny: "I feel worse. And I keep looking."

"Why do you keep looking if you feel worse?"

Destiny thinks about it. "Maybe I think if I keep looking, I'll figure out what I'm doing wrong."

This is the mechanism precisely: upward social comparison with curated content, framed as self-improvement research, producing inadequacy that drives more scrolling rather than resolving it. The algorithm has no incentive to produce resolution. Its incentive is engagement. Destiny's inadequacy-driven scrolling is exactly the behavior the design produces and rewards.

Amara and Destiny unfollow seventeen accounts together in session — the most acutely negative comparison ones. Destiny's physical response as they go through the list: visible discomfort unfollowing some, audible relief unfollowing others. One account she hesitates on for a full thirty seconds before unfollowing. "I've been following her since eighth grade. I've never met her. I don't know why I feel like I owe her something."

Amara: "You don't."

The unfollow.

Francis: The Clinical Thread Continues

Francis's case, which began in Chapter 38 as a cultural humility intervention, has a digital technology dimension that emerges in their eighth session together.

Francis is using social media to maintain connection with his home community in Ghana. This is a genuine function — video calls, WhatsApp groups, photographs of events he is not present for. The digital connection is not producing negative wellbeing in the passive-use sense. If anything, it is a form of the acculturation integration strategy: maintaining cultural identity while navigating a new environment.

But Francis mentions something more complicated. His cousins in Accra post frequently about their lives: family events, celebrations, the texture of daily social life. Francis watches these posts. He describes a specific emotional response that is distinct from social comparison in the conventional sense. It is not envy of others' superior lives. It is grief. This is the life I am not living. These are the moments I am not in.

The filter bubble concern is inverted in Francis's case: the algorithm is not filtering out contrary content — it is delivering with high fidelity the content most likely to produce the sense of cultural dislocation that is his primary presenting concern. His digital life is full of the cultural world he misses, and its presence in his feed maintains rather than soothes the grief.

Amara brings this to supervision. Marcus asks: "What would you do with it?"

"I'm not sure it's pathological," Amara says. "He misses his family and community. The digital connection is real — it's better than nothing. But it's also a form of sustained exposure to the loss. He's watching his life happen without him."

"What does he want?"

"To stay connected. He doesn't want to disconnect. But he said — he said something I've been thinking about: 'When I watch my cousin's wedding on video, I am there and not there at the same time. It is worse than not seeing it at all, and I cannot stop watching.'"

Marcus: "Ambiguous loss."

Amara: "Yes."

The clinical work with Francis around the digital dimension becomes less about changing his digital behavior and more about naming what the digital presence costs: the particular grief of mediated presence, the painful paradox of being connected to what you cannot fully inhabit. This is not a problem to be solved with notification management. It is a loss to be named and held.

Amara adds a note to Francis's treatment file: Digital connection as ambiguous loss — present/absent simultaneously. Treatment focus: naming the particular grief, not changing the behavior. Behavior is adaptive. Grief is real.

Amara's Own Digital Audit

The chapter's exercises require Amara to turn the lens on herself.

The data: - Daily screen time: 3 hours 24 minutes - Breakdown: Social/entertainment — 1 hour 51 minutes; Information — 42 minutes; Communication — 31 minutes; Productivity — 20 minutes - Pickups per day: 44 - First pickup: 7:12 AM - Last use: 11:47 PM

She had estimated two hours, maybe two and a half.

The information environment audit is more confronting than the raw numbers. Amara traces where she gets her understanding of current events, clinical developments, social issues. The feed is predominantly left-progressive; the clinical sources are predominantly contemporary, English-language, American; the cultural reference points are predominantly Western. She thinks about Chapter 38's WEIRD critique applied not to psychology texts but to her own information diet. What perspectives are absent? Which clinical debates is she not encountering because the algorithm has learned what she engages with?

The social comparison inventory is specific: Amara follows fifteen clinical social media accounts — therapists, researchers, counselors building platforms around their practice. She does the exercise honestly. Category: aspirational. Response after viewing: more "I'm behind" than "I'm inspired." These are people a few years ahead of her in their MSW programs, or already licensed, building practices that look cohesive and established. Amara is twenty-four, in her first year, navigating a completely normal developmental stage. The algorithm has given her a clear picture of what she should already be.

She unfollows eleven of the fifteen.

Kemi's response when Amara tells her: "I unfollowed half of them two months ago. I didn't tell you because you seemed to find them useful."

Amara: "Did you find them useful?"

Kemi: "I found them anxiety-inducing. I thought maybe that was just me."

Amara: "It wasn't just you."

The Supervision Conversation

Amara brings the chapter's practical framework to supervision in a different way than she usually presents clinical material. She brings it personally.

"I've been thinking about what it means to be a clinician in an attentionally fragmented environment," she says. "The work requires full presence. That's not an aspiration — it's technically necessary. You can't track what's happening in the room if part of you is monitoring whether you have messages."

Marcus: "And?"

"I check my phone in the five minutes before session starts. I've been doing it as a habit. I think I'm doing a final check for anything urgent. But the research suggests the habitual monitoring pattern carries forward even when I'm not actively on the phone. The Ward study — the mere presence of the phone."

Marcus: "What are you proposing?"

"Phone in my bag, bag in the closet, before the first session. Not on the desk. Not on silent. In the closet. And I want to be honest about why I've been resisting that obvious step."

Marcus waits.

"Because I feel more secure with it available. And I need to examine what I'm looking for in that security, because it's not about genuine emergencies."

Marcus says what he has said before, in different words, in different contexts: "The work is exactly what you think it is."

What the Chapter Means to Amara

Three things stay with her from Chapter 39's content, shaping not just her clinical practice but her understanding of her own life:

The attention economy as environment, not choice. She is a person formed in a culture that has built an enormous infrastructure optimized for capturing her attention and selling it. Her choices about phone use, social media, notification response are not made in a neutral space — they are made in an environment that has been designed with considerable sophistication to produce specific behaviors. This does not eliminate agency. But it reframes the self-criticism that accompanies digital overconsumption: you are not failing at discipline. You are navigating an environment that was built by engineers who are very good at their jobs.

Digital presence as clinical material. Every client she sees inhabits a digital environment. The social comparison patterns, the FOMO loops, the fragmented attention, the sleep disruption, the filter bubbles shaping their understanding of themselves and the world — these are clinical realities, not peripheral context. Her assessments will increasingly need to include the digital life.

The parallel between the attention economy and therapy. This is the thread she brings to Dr. Liang in a rare elective session outside the core curriculum. The attention economy captures attention by providing intermittent reinforcement, social feedback, and stimulation without resolution. Good therapy, Amara says, does something different: it provides the conditions for sustained engagement with difficult internal material, without the escape valve of the next notification. In some sense, a session is an extended exercise in tolerating the absence of variable-ratio stimulation.

Dr. Liang listens carefully. "You're describing attention as the clinical medium. Not just the method — the medium."

"Yes," Amara says. "The therapy relationship is partly attention. The capacity to hold someone fully in mind for fifty minutes, without the pull toward the next thing. That's increasingly rare. That might be part of what makes it valuable."

Dr. Liang: "Write that down."

Amara writes it down.

End of Chapter 39 Case Studies. Key Takeaways and Further Reading follow.

Case Study 02 — Chapter 39: Technology, Social Media, and the Digital Self