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Psychoanalysis Online

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Psychoanalysis Online: Mental Health, Teletherapy and Training, edited by Jill Savege Scharff, MD, is an international collaboration by psychotherapists and psychoanalysts who consider the impact of virtual reality on our society and the uses of communications technology for analytic treatment and professional training. Having examined the impact of communications technology on mental health and relationships, the authors explore its use in analytical treatment conducted on the telephone and over the internet, and review its problems and possibilities. They provide a multi-faceted view of it, an ethical stance in relation to it, and evidence from which to judge its effectiveness. Looking into the future they imagine a time when technology-supported analytic treatment may be not only convenient as a supplement to in-person treatment but also preferable for some patients and therapists in various circumstances. Psychoanalysis Online: Mental Health, Teletherapy and Training invigorates the debate about technology and its responsible use in psychotherapy and psychoanalysis and in distance learning programs for mental health professionals.

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Chapter One : The influence of Social Media and Communications Technology on Self and Relationships

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CHAPTER ONE

The influence of social media and communications technology on self and relationships

Michael Stadter, PhD

As patients enter my office, they commonly turn off their smartphones and electronic tablets, placing them on the table next to them. This actually and symbolically creates a space for reflection and intimate connection between us, uninterrupted by the intrusions of the internet, social media, and communications technology (calls, emails, texting). Some patients comment that this is the only place in their lives where they allow themselves to be free of technology, speaking to its nearly constant presence in their lives. It is a presence that can alter subjective and intersubjective space in a variety of ways and can be a third object in relationships between two people.

I have termed this presence the “e-third” (Stadter, 2012)—the influence of an electronic object in addition to self and other—and we are just beginning to understand its evolving effects for both good and ill. In studying the present and future of e-technology, Turkle (2004) writes, “What we need today is a new object-relations psychology that will help us understand such relationships and, indeed, to responsibly navigate them” (p. 28). The e-third is very different from Ogden's (1994) concept of the analytic third which is created by the individual subjectivities of the therapist and patient creating a third space, an intersubjective third space. In turn, the analytic third profoundly affects the subjectivities of the individual. This is a cyclical dialectic process between the influences of subjectivity and intersubjectivity and between the inner world and the external world of the therapy encounter. It is a space that exemplifies the psychodynamic sensibility of reverie (Ogden, 1997). The e-third also can promote reflection and curiosity. Yet, as illustrated in some of the vignettes that follow, it frequently encourages states of self and relating that can be rushed, distracted, shallow, and fragmented. In short, we need to study not only what this technology can do for us but also what it does to us.

 

Chapter Two : Skype as the Uncanny Third

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CHAPTER TWO

Skype as the uncanny third

Irmgard Dettbarn, PhD

Skyper, an acronym for Sky peer-to-peer, was the original name given to new software designed to make free phone calls possible on the internet in 2003. However, at this time, another domain with the same name already existed on the World Wide Web. So the “r” was simply deleted and Skyper became Skype. In Skype, described as a peer-to-peer network, “…resources and data can be simultaneously exchanged between two networked computers, however, both computers must be on an equal footing, as the name suggests. Using a microphone, the computer records the user's voice; it then converts this information into individual datagrams (or network packets) and sends it via the Internet Protocol (IP) to the respective receiving computer. Thus, the entire data exchange occurs via the Internet. The receiving computer puts the incoming datagrams back together and transforms the data back into language that is delivered via a loudspeaker” (www.voip-information.de/peer-to-peer.html).

 

Chapter Three : The Computer as Metaphor for State of Mind

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CHAPTER THREE

The computer as metaphor for state of mind

Karen Sharer-Mohatt, PsyD and Jill Savege Scharff, MD

We will present clinical material to show how computer technology that is a substitute for relating can become a vehicle for being understood. Describing frustrating work on the computer reveals the patient's dynamics, his defences, and his relationship to his analysis. As the analyst listens and interacts with him in the language of technology, she sees the computer as a metaphor for his state of mind and his feelings about his treatment and her.

Mr. X is a depressed, divorced man whose only affectionate relationship is with his cat. He has not had a relationship or even a date with a woman since he broke off with a woman he still longs for, but has not contacted since she married another man. An electronics technician, he works too many hours in a boring job repairing electronic equipment in communication devices, and feels too tired and overwhelmed to keep up with the repair projects in his own home. He spends his time on computer programming and games instead of dating and taking care of his home. His greatest pleasure is to retreat into sleep, sometimes for a whole day. He acknowledges how depressed he is, and how hopeless he feels, and having been in therapy twice, he is convinced of the need for analysis but unsure of its value. A man who spends money frugally and mainly on computer products, Mr. X had to calculate his finances and his analyst's worth before making a commitment to analysis. He meets her four times a week, attends regularly, and is now in the early middle phase of analysis. We will now provide vignettes from a series of sessions to show how Mr. X expresses his issues in the language of technology—programs, text, chat, and rebands (changing the frequency on a radio). The analyst will now take over in the first person to present relevant parts of the analytic dialogue interspersed with her unspoken thoughts in italics.

 

Chapter Four : Internet Pornography as a Source of Marital Distress

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CHAPTER FOUR

Internet pornography as a source of marital distress

Sue Cebulko, PhD

The relationships married women have with their pornography using husbands are complex and complicated. Wives and husbands engage in a continuous cycle of discovery, confrontation, demands for change, ultimatums, extraction of promises of change, forgiveness, and return to relative peace. Husbands and wives maintain a state of denial, except when crises of compulsion, discovery, and betrayal break through until reassurance and forgiveness re-establish the status quo and the cycle is reinforced. All the women struggle internally and externally with this issue. It impacts their spiritual, emotional, sexual, intellectual, and relational lives.

When I made my study of these relationships (Cebulko, 2007) I focused on wives of pornography using men, and I employed a psychodynamic perspective to study and increase the depth of my understanding of the experiences of wives whose husbands use the internet for pornography. I found that many of these women had experiences of traumatic developmental interferences that seemed to hinder their efficacy in managing their lives. From the beginning of the relationship, the women managed not to acknowledge early indications of their partners’ sexual proclivities and other compulsive activities. Untreated trauma and individual personality characteristics influenced both the choice of spouse and the inability to disengage from problematic marital dynamics. Once married, and faced with the reality of pornography, the wife tended to focus her concern specifically on the husband's internet pornography use, even when he was engrossed in other sexually related activities and numerous other compulsions.

 

Chapter Five : Musings on Therapy and Technology

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CHAPTER FIVE

Musings on therapy and technology

Sharon Zalusky Blum, PhD

We are living in an ever-changing, highly mobile world where new technologies continue to alter the way people are born, live, relate, and die (Zalusky, 2000). New modes of communication are exploding rapidly, transforming the ways in which people connect across boundaries. As therapists we find ourselves in an unusual position. The seclusion, the privacy of the therapeutic encounter, and removal from everyday life—all have long been considered necessary components for change to occur. Yet privacy as we have conceptualised it no longer exists. The sanctuary, the perfectly constructed cocoon where patient and therapist could create a transformative experience, is constantly being trespassed upon by the ring of cellphones, the notification sounds coming from text messages, emails, and Facebook, all signifying that the outside world has entered the confines of our offices.

The myth of the anonymous analyst has taken its last breath. It is only the most technologically removed or constricted patients who would not first do a Google search of their prospective therapist before beginning treatment. Often, when analysts or therapists have written papers, their publication history if not the papers themselves can be found online, which has a direct implication for confidentiality. This access on Google generally has changed the practice of writing up cases. As a consequence the tenor of our psychoanalytic literature is changing as well.

 

Chapter Six : Clinical Issues in Analysis Over the Telephone and the Internet

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CHAPTER SIX

Clinical issues in analysis over the telephone and the internet

Jill Savege Scharff, MD

Teletherapy, the practice of psychotherapy conducted remotely using the telephone and the internet, is increasing in response to more mobility in the population. In psychoanalysis, more than in psychotherapy, there has been tremendous worry about violating the purity of the classical method when sessions are conducted on the telephone or over the internet. Some have said that any analytic treatment done by an analyst working with an analysand on the telephone may do some good but it cannot be analysis: it must be supportive psychotherapy (Argentieri & Mehler, 2003). I find this remark rather unfair to the practice of psychotherapy, but rather than get distracted by jumping to defend psychotherapy, I want to use this chapter to focus specifically on the value of psychoanalysis conducted over the telephone and the internet. Since teleanalysis occurs three to five times a week, those of us who practise it have an opportunity to study its pros and cons in depth over time. Our findings can be helpful to psychotherapists who do not have the luxury of time, and analysts who have not tried to work with patients at a distance using the telephone or the internet.

 

Chapter Seven : Legal, Clinical, and Ethical Issues in Teletherapy

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CHAPTER SEVEN

Legal, clinical, and ethical issues in teletherapy

Angela Carter Martin, DNP, APRN

Our society has moved towards the use of technology in most aspects of our lives. It is no surprise that mental health education and treatment are moving in a similar direction. Some research looking at the different therapy modalities of audiovisual, audio, and text communication found that they provide equal benefits when compared to in-person therapy and that they may offer certain advantages (Anthony, Nagel & Goss, 2010). As patients demand access to mental health treatments beyond the clinic or private office, therapists are offering technologically mediated therapies (commonly known as telemental health) as part of their practices. Yet educational programmes often lag behind patients’ and therapists’ interest in treatment that is not place- or time-bound. A significant number of clinicians who have no preparation for conducting treatments outside the consulting room are not prepared for the multiple issues inherent in the use of technology to deliver services. The purpose of this chapter is to clarify some of the major ethical, legal, and practice issues therapists should consider when preparing to deliver mental health services through the use of technology.

 

Chapter Eight : Ethical Aspects of Teletherapy

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CHAPTER EIGHT

Ethical aspects of teletherapy

Ernest Wallwork, PhD

After more than two decades of conducting phone and, more recently, Skype therapy and psychoanalysis with patients in the two distant cities where I practise—Syracuse, NY and Washington, DC—I am convinced by personal experience with a diverse group of patients, as well as by the reports of colleagues, that good-enough psychodynamic therapy and analysis can be conducted with most patients with the help of the new technologies. The benefits of remote treatment are not for everyone, however. Some patients are just not able to engage affectively via telecommunications technologies. But most are, and for these patients, the benefits of continuing and deepening a treatment by phone and Skype can be enormous and, often, life-altering. The same ethical principles apply in both in-person analysis and teletherapy but there are some unique ethical aspects of teletherapy.

An ethically significant issue related to the analyst's psychic presence in teletherapy

 

Chapter Nine : Impact of a Single Skype Session on an In-Person Analysis

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CHAPTER NINE

Impact of a single Skype session on an in-person analysis

David E. Scharff, MD

Elements of the frame are of primary concern in the conduct of analysis. In an analysis that proceeds well, they often become all but invisible as the context for work. When there is a sudden shift in the frame, our attention may be called unexpectedly to elements of the patient's life and way of adapting that had been obscured behind the mask of the everyday. Such is the case in the following example of a shift in the frame, or perhaps more precisely in the mode of communication for the analysis, which highlights elements of transference and brings insight into the patient's problems. This patient's adaptation to the relational problems in her life consisted primarily of withdrawal from having any positive expectations from the important people in her life and this led to a chronically depressed attitude towards what life might bring. I had known that she was quite adept with computer technology, but had not appreciated how much of an investment she had made in this in a life otherwise devoid of passion or interest.

 

Chapter Ten : Transition from In-Person Psychotherapy to Telephone Psychoanalysis

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CHAPTER TEN

Transition from in-person psychotherapy to telephone psychoanalysis

Nancy L. Bakalar, MD

Psychotherapy by telephone allows us to offer treatment to patients who may not otherwise have access to it: those in rural areas; those in high-density population areas in which commuting is excessively time-consuming and onerous; and those for whom, like patients in conservative religious communities, in business or politics, a higher degree of privacy may be required. In the three cases presented here, telephone sessions allowed for continuation of treatment, after I had moved to another state, for patients who had made a hefty investment in their treatments up to that time. Two of the patients are women who transitioned from in-person psychotherapy to telephone psychotherapy, and eventually to four times weekly telephone psychoanalyses, and the third patient is a man who had not been able to attach to the therapeutic process in person but was later able to develop a telephone treatment. Following the transition to telephone psychoanalysis, the two women reacted with intense negative transferences. Using concepts from Klein, object relations theory, and Bion, I hold the frame, follow the affect, and process and interpret the response. I apply the usual analytic functions of holding, containment, and interpretation, just as I would do in in-person analysis.

 

Chapter Eleven : Setting and Transference-Countertransference Reconsidered on Beginning Teleanalysis

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CHAPTER ELEVEN

Setting and transference-countertransference reconsidered on beginning teleanalysis

Asbed Aryan, MD

The ethics of psychoanalysis include an expectation that psychoanalysts will continue to learn about new theory, paradigms, and clinical techniques that extend the applications of psychoanalysis and lead to philosophical, sociocultural, scientific, and economic transformations. We can no longer depend only upon the classic, known practice of psychoanalysis. What were once new developments are now clinical facts. What were once obstacles are now opportunities for research into areas beyond what had so far been seen, known, theorised about, and put into practice. When a new clinical problem arises, before we try to build a new theory to account for it, we think of it as a variant of what we already know. But when this new problem is found in several of our patients, and those of colleagues, and when it defies our current theories and techniques for trying to understand it, we must see this problem as not only the patient's problem, but a problem arising from limitations of our psychoanalytic method.

 

Chapter Twelve : Case Material from a Telephone Analysis

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CHAPTER TWELVE

Case material from a telephone analysis

Charles Hanly, PhD

K was a striking, highly intelligent married professional woman in her late twenties. Despite her attractive appearance, her intellectual and professional achievements and her marriage, she remained narcissistically vulnerable and subject to panic attacks.

K had telephone analysis at four times per week for three years after one year of analysis on the couch preceded by more than a year of psychotherapy. When her husband was offered an excellent career opportunity in a city at a great distance from Toronto we both knew that she had more work to do, especially in working through dependent ties to her parents and their surrogates. I recommended that she should continue her analysis with a colleague in the province to which she was moving. However, the distance between her new home and the city in which analysts were located ruled out this possibility. K did not want to change analysts: she was feeling understood and she no longer had panic attacks, although fear of them persisted. When K asked me for analysis by phone, I agreed with trepidation.

 

Chapter Thirteen : The Screen as Catalyst for Psychic Transformation

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CHAPTER THIRTEEN

The screen as catalyst for psychic transformation

Caroline M. Sehon, MD

Is intensive psychoanalytic psychotherapy via Skype indicated or contraindicated for patients with an intense internet life? Can therapy by Skype foster the growth of patients who have a long-established preference to socialise in cyberspace? In this context, would the patient's comfort with communication technology leverage the work so that patient and therapist can work more analytically? How can we understand the mechanisms for therapeutic action for such patients?

As a participant of the international working group on teleanalysis at the International Psychoanalytical Association, I pondered these questions before and after I agreed to continue therapy via Skype with a college-bound adolescent patient who needed to work in this way to stay in therapy with me. We were both surprised when his therapy and life took quantum leaps forward to a degree that could not simply be accounted for by other factors. I would like to discuss major signs of progress in my patient, and data to suggest the critical role that Skype served in deepening our work. In conclusion, I will offer some hypotheses for how his significant transformation might be understood as directly attributable to our work via the screen.

 

Chapter Fourteen : Clinical and Technical Perspectives on Telephone Analysis

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CHAPTER FOURTEEN

Clinical and technical perspectives on telephone analysis

Jaime Marcos Lutenberg, MD

Telephone analysis should enable analyst and patient to comply with two of the fundamental conditions of analytical technique: the analysand must be able to engage in free association, and the analyst must be able to use suspended attention. Is it possible to conduct a psychoanalytical treatment using the telephone as the means of contact between the patient and the psychoanalyst? What technical and clinical issues arise?

To address these questions I will give passages from two consecutive teleanalysis sessions with commentary in italics to show my work style and way of thinking. I will then review my application of theory of psychoanalytical technique to my work as an analyst. In summary, my ideas are based on Freud who gave us an epistemological, ethical, technical, and theoretical path to follow in doing psychoanalysis. He also guided our research work along new lines of investigation. My ideas are also based on Bion's theory and the influence it has on psychoanalytical technique. The psychoanalytical process that I believe is possible in session on the telephone conforms to the standard analytical process described in their writing and in Etchegoyen's Los Fundamentos de la Técnica Psicoanalitica (1986).

 

Chapter Fifteen : The power of the Establishment in the Face of Change: Psychoanalysis by Telephone

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CHAPTER FIFTEEN

The power of the establishment in the face of change: psychoanalysis by telephone

Asbed Aryan, MD and Ricardo Carlino, MD

Psychoanalytic thinking which departs from traditional doctrine sometimes encounters difficulty in being conceptualised and developed within the framework of the institution for psychoanalytic education. We will consider the obstacles that arise with the arrival of psychoanalysis practised by telephone.

Power and the vicissitudes of a new idea

We base our argument on some of Foucault's ideas regarding power (Diaz, 1995). In an institution, the intertwined synergy of power by agreement among the participants operates, devoid of antagonistic rivalry or subjugation, in a way that supports leadership and the orderly exchange of ideas among them, and also allows for the dynamic reconfiguration of their changing and emerging relationships. If this consensus on the quality of power in the institution breaks down, power may be used individually to intimidate, dominate, or commit an act of violence against another participant's point of view. The field of ideas is a territory throughout which thinking constantly moves. From time to time, a new idea emerges to meet changing needs or provide a better explanation than we have currently. New responses are called for when a new complexity is appreciated in the subject under study, or when an error is detected, or a gap in understanding must be filled in. We need to rethink, modify, or elaborate on established ideas in the light of new information and trends. As we look at the impact of telephone analysis on the institution of psychoanalysis, we consider the members as individuals (intra-subjective level) operating with colleagues (inter-subjective level) and as part of a community (trans-subjective level).

 

Chapter Sixteen : The frame for psychoanalysis in cyberspace

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CHAPTER SIXTEEN

The frame for psychoanalysis in cyberspace

Debra A. Neumann, PhD

The internet is playing an ever increasing role in society, and not surprisingly in psychoanalytic practice as well. Yet it remains a controversial endeavour. In this chapter, I examine some issues that emerge for patient and analyst when using internet videoconferencing for treatment. My main focus is on establishing and maintaining a psychoanalytic frame within which an analytic process can develop. Then I examine some objections to psychoanalysis in cyberspace, pose questions raised for current psychoanalytic understandings of time and space, and suggest areas for future exploration.

In spite of practical, theoretical, and political disputes regarding its merit, teleanalysis on the internet is currently emerging as a prominent feature of contemporary analytic practice. In fact, Gabbard (2001) has drawn a parallel between the frontier of the American West and the position of cyberspace in analytic practice. But the frontier reaches beyond the United States. The China American Psychoanalytic Alliance (CAPA), a non-profit organisation incorporated in 2006 to develop and promote mental health services in China by training Chinese mental health professionals in psychoanalytically oriented psychotherapy, uses the internet extensively for instruction and supervision. CAPA strongly encourages its students in China (all of whom are mental health professionals) to undergo psychoanalytically oriented psychotherapy or psychoanalysis during their training by means of computer to computer video technology using the commercial service Skype. The rationale for this unorthodox practice of psychoanalysis is that, while many Chinese mental health providers are interested in learning about psychoanalytic theory and treatment, there are very few analysts in China who can provide them with training or treatment.

 

Chapter Seventeen : Psychoanalysis Using Skype

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CHAPTER SEVENTEEN

Psychoanalysis using Skype

Anna Kudiyarova, PhD

I would like to discuss the usefulness of Skype for providing psychoanalytic treatment. Nowadays there is a big discussion about the question: should we officially recognise psychoanalysis conducted via Skype or not? My answer to this question is unequivocally, yes, we should. But I have only gradually come to such a conclusion. I first heard of psychoanalytic sessions on Skype from my colleagues, candidates in training under the auspices of the International Psychoanalytical Association. Being very obedient to all analytical rules, my first reaction was indignation and anger. How might anyone think that it was possible? This was a violation of the setting! But many analysts and candidates in the post-Soviet regions have no other option. Having tried it, I have found Skype to be an extraordinarily useful medium in which to practise psychoanalysis and psychoanalytic supervision. So I would like to share my experience in this field, to explain the way it is done for those who have not used Skype, and to present some clinical cases via Skype to show how closely they resemble in-person sessions. Today, I use Skype for sessions in three ways: 1) in supervision as a supervisee and as a supervisor; 2) in analytic treatment with my own analyst, and 3) in analytic treatment for my patients who live in remote cities in my country, Kazakhstan, and other countries. I will focus mainly on the treatment applications of Skype.

 

Chapter Eighteen : Four Women Analysts Reflect on their Teleanalyses when Candidates

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CHAPTER EIGHTEEN

Four women analysts reflect on their teleanalyses when candidates

Betty S. de Benaim, PhD, Yolanda G. de P. de Varela, PhD, Lea S. de Setton, PhD and Anonymous, PhD

Like most candidates, we would generally prefer in-person analysis, but there were no analysts in our place of residence in Panama and our family commitments did not permit relocation to a centre of psychoanalytic training. So we were grateful to have the option of teleanalysis, some of us using the telephone and some of us preferring Skype, each of us to varying degrees of satisfaction with the use of technology to have psychoanalysis. The use of technology also made it possible for us to participate in a distance learning programme of psychoanalytic education. After graduation we all brought clinical expertise and theoretical knowledge to share with other mental health professionals. Each of us will now share some thoughts on the theory and technique of teleanalysis compared to traditional in-person analysis, based on our reading and our personal experience. As we proceed, we prefer not to indicate which of us is the “I” in our individual narratives in order to protect the privacy of our patients and ourselves.

 

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