Technology, teleanalysis and teletherapy

How does technology impact the human mind?  Developmental, neuroscientific research and clinical experience confirm our personal impressions that all-embracing communication technologies are reshaping our ways of thinking and relating.  Some of us worry about the widespread use of the internet changing our capacity to connect, create, and love.  We have seen young adults who would rather interact on text with many people via a hand-held device than relate intimately to those who are present at the dinner table. They find others with shared experience and perspectives, indulge in sexual fantasy, and find a space for belonging.  Has undivided attention lost its value?

How does technology affect the therapist’s way of life? We all know the experience of being Googled, bombarded by 100 emails, streams of information, and requests for instant response. Will we adapt to the pace of change, the rapid multitasking, the diffusion of our attention across many work and social networks?  As therapists, must we always meet out patients in person in our own office for clinically effective, confidential work to happen?  Or can we harness internet technology effectively and ethically to provide care for our patients as they adapt to the demands of the internet age?  Can we use it to provide training opportunities for therapists and psychoanalysts who want to develop their clinical skills?

In Psychoanalysis Online 2 (2015), we develop our ideas and positions on the use of technology in the practice of psychoanalysis and its application to psychotherapy, first introduced in Psychoanalysis Online (2013). We think it is possible to develop an effective, ethical treatment. First we have to set a responsible frame for the treatment, respecting local and national legalities and rules for licensing, maintaining internet security, and making a mutual assessment of the values and risks of using the Internet in treatment. Then we have to study the practice of teleanalysis and teletherapy, learning from each other and sharing our research. Many of the contributors to Psychoanalysis Online 2 have been collaborating in a teleanalysis workshop and research group to study the issues presented in ongoing, intermittent, and occasional teleanalytic sessions with adults in analysis, children in analysis and therapy, and couples in analytic couple therapy. From this working group we have developed the ideas that we are now sharing.

Usually the kind of distance treatment we are referring to is conducted verbally on the telephone or on an internet protocol augmented by a web camera, but one of the chapters presents a detailed analysis of a text-based intervention for a suicidal patient who could not attend in-person sessions during summer travel by her analyst and herself. Even when the treatment is speech-based in real time, we recognize that teleanalysis is not the same as in-person analysis (even though we find that if we study process notes, we cannot tell whether the sessions took place in person or in virtual space).  For a start, the teletherapist does not control the provision of the environment in which treatment will take place. Teletreatment calls for the patient to take more responsibility for the setting, and it requires the analyst to develop many channels other than the visual reception of body language for picking up the transference. If we can acknowledge the limitations and work with them, we can offer a “good enough” setting that supports deep unconscious communication, and sustains a transformative analytic process.

Having had some experience with the practice of teleanalysis and teletherapy, the contributors have been sought-after as teachers, consultants, and clinical supervisors for therapists who want to practice remotely because of the needs of patient or therapist. One or the other may be traveling, living in two locations, required to move, or immobilized temporarily, and they need help to adapt their treatment protocol. They cannot travel to a supervisor or a course, and so they consult us regularly or intermittently via telephone, tablet, desktop computer technology, or videoconferencing system. Technology definitely affects the dynamics of the teaching or supervision, and as long as these are accepted, tolerated, and analyzed, then technology is invaluable in dissolving the barriers of geographic separation from expertise.

A single session of tele analysis can be more effective at times than a session in person and may even lead to a turning point.  An inexperienced teleanalyst might read the negative transference to teletherapy as a reason to end the treatment and make a referral, but if the analyst sees beyond the technical aspects to the dynamic unconscious reasons for discomfort in the expanded virtual space, then treatment can be secured, continuity of care maintained, and the analytic process deepened. It is even possible to play therapeutically with a child screen-to-screen. For schizoid personalities, the lack of relatedness in life can be recreated in the sense of all that is lacking in online communication, and, once understood, then that which did not happen in early life may happen in the future of the analytic relationship. In Psychoanalysis Online 2 we propose that harnessing technology to our aim of providing care for those who cannot come for treatment in our office, and training for therapists who live far from an analytic training center, gives us a way of preserving analysis as a sanctuary for reflection.

Jill Savege Scharff, MD, is co-founder of the International Psychotherapy Institute; Supervising Analyst at the International Institute for Psychoanalytic Training; Clinical Professor of Psychiatry at Georgetown University; and psychoanalyst and psychotherapist with individuals, couples and families in Chevy Chase, Maryland. Jill is an author, editor and series editor of many books, several co-authored with David E. Scharff. Her latest edited work, Psychoanalysis Online 2, is published this week by Karnac Books.