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Distance Psychoanalysis

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'Many analysts around the world have found themselves in a situation of continuing (or even beginning) psychoanalytic treatment from a distance - either by telephone or other means of communication. No one has found the courage, however, to recognize this as a formal method, as Ricardo Carlino does in this brave, honest, and rigorous book.'Freud's ingenious structure of the couch and chair was considered to be the only suitable format for more than one hundred years. Carlino's lucid book takes into account the changes that have taken place in our daily lives, as the result of the resounding technological changes that have influenced our means of communication.'Carlino has had the courage to assimilate the changes that have come about in the modern world and argues that Freud's psychoanalytic method can continue to be applied in this new setting. The analytic system, with a patient freely associating his/her occurrences, together with an analyst who listens in silence and communicates his/her interpretation, has remained unaltered. This is precisely what Carlino develops so thoroughly in this book. Although the modus operandi has changed, the spirit of the analysis remains the same as always.'This is an interesting and thoughtful text that will allow for the spread of analysis to other areas, whenever circumstances force us to reformulate our task. It is a book worth reading and will, no doubt, bring about reflection, debate, and a fruitful exchange of ideas.'- R. Horacio Etchegoyen

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PROLOGUE FOR THE SPANISH EDITION

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Writing the prologue of a book is a great responsibility, both to its author and to its readers, given the multiple communication involved. A prologue also involves a subjective perspective, no matter how objectively one tries to describe the content of the book. Distance psychoanalysis is a subject which puts colleagues prejudicially “in favour” or “against”, whether they may be the author of the prologue or the reader of the book. I will try to limit the enthusiasm I share with the author for this subject in order to transmit the scientific criteria with which Ricardo Carlino addresses the topic. I would like to avoid the feelings of passion and adverse politicization that are typically provoked when this subject is addressed in an institution or psychoanalytic congress, whether it be national or international. Likewise, I will avoid going into details about the treatment that most new ideas and authors of those ideas tend to receive at the onset.

To my knowledge, this is the first time that a book dedicated to this subject and written in the Spanish language has seen the light of day. Those who need to compare their similar clinical experience will find a text which serves as a wonderful source for finding the answers to their questions. Those non-believers who simply express that “Distance psychoanalysis is not psychoanalysis” will find here a great deal of theoretical, clinical, and epistemological material upon which to discuss and express their opinions.

 

INTRODUCTION

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The intention of writing this book is to contribute to the establishment of a theoretical and technical framework for distance psychoanalysis, which is a therapeutic practice that in our society still has the taste of “individual daring”, given that it is not a classically instituted technique. This book has the objective of making an important and significant contribution to this subject. Psychoanalysts will find a solid theoretical-technical base that will contribute to the decentralization of established practice as something fixed and absolute. I have observed that a way of implementing something tends to be “confused” with the essence of that “something”. Psychoanalysis can and must be open to new conceptions due to the traversing and permanent reconstruction that socio-cultural transformations produce in human beings. It is necessary to stop and think conceptually about this new psychotherapeutic possibility, which, in fact, is already becoming a reality. I propose this in the hope that it will become a processed conception in psychoanalytic institutions. It needs this seal of authentication in order to be held with the necessary stature at the moment of implementation.

 

CHAPTER ONE: Socio-Cultural transformations: their influence on psychoanalysis

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Psycho-analysis an Empirical Science:

Psycho-analysis is not, like philosophies, a system starting out from a few sharply defined basic concepts, seeking to grasp the whole universe with the help of these and, once it is completed, having no room for fresh discoveries or better understanding.

—Freud, S. (1923a)

This epigraph contains the view on psychoanalysis that Freud (1923a) included in “Two Encyclopaedia Articles: Psychoanalysis and Libido Theory”. It summarizes in concise form the epistemic spirit that encourages any researcher.

Socio-cultural changes and technological innovations that settle into and circulate within society affect both reality and people’s subjectivity. At the present time we see so many changes in so many social customs that we easily perceive their influence. It is up to each individual to decide how to receive them, contemplate them, and what to do with them.

This term refers to an elementary and axiomatic position from which each person feels, thinks, reads, listens, and elaborates his/her own feeling and thinking. This base logic operates as a determining factor at the moment of adopting a decision or conduct. It is the product of a combination of knowledge, beliefs, norms, and values, which produce a mental stance and attitude functioning as an axiom or point of reference. It functions in the mind as a lens through which one can observe, understand, and give meaning. It is a starting point from which to interact with the world and with oneself. It works subliminally like a permanent transparent lens which goes unnoticed by the person who uses it. Observing reality through this lens offers a perspective which leaves proof of its existence. It produces a sense of orientation that promotes a tendency and determines a certain stance when facing stimulants coming from within or from the surrounding world (Carlino, 2000).

 

CHAPTER TWO: Technology and its influence on subjectivity

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We are now quite far from the early stage of a culture which, at times, was very interested in recognizing its surrounding reality in visible and concrete terms. In that archaic evolutionary stage of our species it was a great cognitive achievement to be able to distinguish that which had a concrete, tangible, and perceivable existence from that which could be an unworldly entity and/or product of hallucination.

We can see that in this conception, all that was real and concrete was set against all that, although possessing some type of existence, belonged to the category of the imaginable or the evocable. The evolution of this latter category gradually gave rise to the concept of “the virtual”. When mankind learned to distinguish that a drawing or a word evoked the original object—that is to say, it represented it but it was not the same as the real object—a true advance in knowledge came about. In the psycho-semiological examination of a patient it is necessary to observe whether he/she understands this difference, given that it acts as a dividing line serving to differentiate a perception from an illusion (deformed perception of an object) or from a hallucination (perception without an object).

 

CHAPTER THREE: Communication technology and its articulation with clinical psychoanalysis

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By way of introduction to this chapter, it is important to include some discussions on the subject carried out at the 46th International Congress of Psychoanalysis (IPA), held in July of 2009 in Chicago.

Estrada Palma presented a survey carried out by email and directed to 60 psychoanalysts in Latin America who are engaged in the field of teaching. Thirty-two of these psychoanalysts, that is to say, more than 50%, responded. The survey asked these analysts whether they had added communication technology to their habitual framework. The following are the most significant data.

The results of this survey are quite interesting. Of the 32 surveyed analysts, 25 answered that it is possible to carry out distance psychoanalytic psychotherapy, and 24 of them have had experience in sessions of this type. Twenty-three analysts—72% of the sample—said that they would accept continuing psychoanalytic psychotherapy by telephone, but only after it had begun in the psychoanalyst’s office. Fifteen analysts—47% of the total—answered that they would accept continuing psychoanalytic treatment by telephone. On the other hand, only 33%—11 analysts—said they would accept that the analysis be conducted by telephone from the very beginning. It is relevant that only 53.3% of those contacted responded to this survey. These answers can be considered to be quite frank. Furthermore, they have a proportional importance to the professional stature of those surveyed, given that all of them are engaged in the field of teaching and in training analysis. In Chapter Seven, we will see the answers referring to the incorporation of analytic dialogue through written chat and email.

 

A SIMILARITIES

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One operates with the conceptual baggage that comes from the fundamental concepts of psychoanalysis, adding the theoretical currents to which each analyst adheres:

•  All of Freudian meta-psychology, expressed in a stratified psychic apparatus in instances; the theory of repression and that of psychosexual development in its economic, topical, and dynamic aspects.

•  The theory of the unconscious and its derivatives: the analysis of the dreams, oneiric symbology, and Freudian slips.

•  Repressed infantile sexuality, the Oedipus complex.

•  Theories regarding identification.

a. One works with an analytical contract that includes a framework that circumscribes the dialogue within a session. Elements such as: “Fundamental Rule”, “free association”, “free-floating attention”, “transference”, and “countertransference” are viable in synchronous distance psychoanalysis. In the asynchronous analyses, such as email, the “Fundamental Rule”, and the “free association” take on a special characteristic that will be discussed in Chapter Seven. b. The first perceptive station hits the sensory organs that the applied technological means allows for. In any case, the sensory apparatus being used perceives what the complex preparation within the mind of the analyst has made available for perception. The saying “he who knows, sees” illustrates this. From that complex perceptive preparation the analyst observes: whether the patient calls at the agreed time, the ideo-affective and behavioural material of the beginning of the session, and the response given to the interpretations. Free-floating attention is the suitable way of catching what is inferred as “the latent content of the material”. When the analyst deems it advisable, he/she interprets and then is attentive to the answer given to his/her interpretation. He/she perceives the patient not only in his/her speech but also in any omissions from this speech. The analyst observes the qualities of the ambience of the session, as well the silences, and what these can say or suggest. In synthesis, the analyst perceives the complete performance of the patient; not only through the sounds and images that reach him/her by means of the technology being used, but also from the mental processing of everything that happens during the session.

 

B DIFFERENCES

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It is necessary to include within psychoanalytic theory a re-conceptualization of the traditional use given to the terms real and virtual. Given that language is transmitted through a means of communication technology which would commonly be denominated as virtual, one can permanently debate whether this dialogue is real or virtual. It is necessary to define this considering the following:

The first three elements that are discussed below [a., b., and c.], legitimately include distance analytic dialogue in the category of real dialogue (non-virtual). In fact, from the points of view taken into account, one observes no difference with dialogue carried out in the analyst’s office.

a. Distance analytical dialogue can only occur in a session arranged for a specific time on a specific day.

b. It is hoped that it will produce effects that will contribute to the analytic process.

c. I t is an act carried out with professional responsibility and subject to legal and tax regulation. The patient pays and the analyst charges for the service.

 

CHAPTER FIVE: Scope and limits of analysis carried out with communication technology

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Freud (1923a) in “Two encyclopaedia articles” defines psychoanalysis very concisely in the first paragraph. In this paragraph, he states what he believes that this term encompasses conceptually:

1. of a procedure for the investigation of mental processes which are almost inaccessible in any other way,

2. of a method (based upon that investigation) for the treatment of neurotic disorders and,

3. of a collection of psychological information obtained along those lines, which is gradually being accumulated into a new scientific discipline.”

Laplanche and Pontalis (1967) in Vocabulaire de la Psychanalyse (The Language of Psycho-Analysis, 1973), based on the contents of the article published by Freud, along with the cumulative criteria in the 45 years following its publication, provide an expanded definition, but without detracting the essence of the original paper of Freud:

Discipline founded by Freud, whose example we follow in considering it under three aspects:

1. As a method of investigation which consists essentially in bringing out the unconscious meaning of the words, the actions and the products of the imaginations (dreams, fantasy, delusions) of a particular subject. The method is founded mainly on the subject’s free association, which serve as the measuring-rod of the validity of the interpretation. Psycho-analytical interpretation can, however, be extended to human productions where no free associations are available.

 

CHAPTER SIX: Clinical anecdotes

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This chapter includes some stories taken from clinical experiences.

The first two are intended to illustrate how two separate analysts, whom I will identify as Analyst “A” and Analyst “B”, for the circumstances that I will describe, establish a telephone treatment for the first time. One of them takes place in a stable setting and the other as complementary to an office setting.

Three years after having interrupted his analysis, a 33-year-old male engineer, who was married with three sons, contacted his former analyst via email. He had emigrated to Europe two years previously. Taking advantage of his annual visit to Buenos Aires for the holiday season, he requested an interview to be held shortly after his arrival. In the course of this interview, he explained that he was distressed by the difficult work situation that he was going through. He further recognized that he was partly to blame for this and that he was terrified about losing all that he had built as a result of his migration. Anticipatory anxiety was the most noticeable symptom. He wanted to protect himself from all possible contingencies, predicting very difficult but imaginary situations that could take place in the short or medium term. Although he knew he was exaggerating, he could not stop guessing and behaving as if what he was thinking were a real or imminent event. As this was a patient who already had a bond with the analyst, and because his stay would be limited to thirty days, both agreed in the first interview that it would be advisable to schedule five sessions per week with the idea of completing a total of twenty. A week after beginning, the patient calmed his anxiety and began to link the reasons for it to situations that made him remember his own childhood home. Motivated by the sensation that the remaining sessions were not enough, he decided to lengthen his stay by ten days. Furthermore, a couple of sessions before his return, he suggested: “Can’t we continue doing this by telephone? What we did helped me to face the problems that I brought to the interview but by talking and talking, other things have come out, and they’re still hanging in the air.”

 

CHAPTER SEVEN: Clinical psychoanalysis carried out in written form

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“Suppose a painter sees a path through a field sown with poppies and paints it: at one end of the chain of events is the field of poppies, at the other a canvas with pigment disposed on its surface. We can recognize that the latter represents the former, so I shall suppose that despite the differences between a field of poppies and a piece of canvas, despite the transformation that the artist has effected in what he saw to make it take the form of a picture, something has remained unaltered and on this something recognition depends. The elements that go to make up the unaltered aspect of the transformation I shall call invariants.”

—Transformations. W. R. Bion. (1965)

The written form of therapeutic communication can achieve considerable importance in clinical experience. This premise justifies that the topic be included in a chapter in this book. This form of treatment includes the written word as a major player in analytic dialogue. It will play a rich, complex, and diverse role. It serves as a first destination to which the ideas born in the mind arrive. As it is used for reasons of conversational exchange, it sets itself up as a container and also as a suitable vehicle for contact for the conversational encounter.

 

CHAPTER EIGHT: Public and private law considerations of distance psychoanalysis

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Ricardo Carlino and Julian Hermida

From a legal point of view, it is not advisable to treat a patient without knowing his/her full identity. Each time an analyst and a patient agree to carry out treatment, they both place themselves in a situation of facing potential legal liability. The analyst must disclose his/her full name, university degrees, professional licence, and address—both geographic and electronic. In turn, the patient must disclose his/her full name, age, gender, and address.

When the analyst and patient reside in different countries, the analyst should be aware of the laws in his/her own country, the applicable laws in the patient’s country of residence, and the Private International Law rules on conflict of laws of both.

Should there be a lawsuit, whether it be in the analyst’s country, the patient’s country, or even a third country, the court that receives the lawsuit must first determine whether it has jurisdiction to accept it. Subsequently, the substantive rules, i.e., those rules applicable to the case, must be established. The court that accepts the claim must also determine the procedural rules, i.e., those which will govern the case. In most cases, procedural rules coincide with substantive rules.

 

EPILOGUE

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In this work, as one might expect, I have not been able to register all my thoughts on the topic due to the fact that some of these ideas are still emerging or are in a state of spontaneous occurrences that come and go. That is to say, they have not yet been methodically processed, which gives rise to the Latin expression: verba volant, scripta manent (spoken words fly away, written words remain).

I have tried to convey the product of both conceptual experience and life experience that I have acquired in hours of distance analysis. This experience has also been promoted in various scientific presentations, panels, discussion groups, and presentations at international congresses, symposia, and workshops. It is also the product of dialogues with colleagues in supervising both their own clinical material and that of others who are interested in this issue.

While there are always elements to consider regarding the possible twists and turns that any rich and complex topic like this entails, I believe that those which have been developed here are sufficient so as to enable an analyst with sufficient clinical experience to initiate distance psychoanalysis. However, much remains to be done and to be written.

 

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