Psychoanalysis Online

Mental Health, Teletherapy, and Training

Jill Savege Scharff

• Publisher: Routledge
• Year: 2018
• Topic: Psychology
• eBook ISBN:
  9780429917837
• Subtopic: Education in Psychology
• Index: Psychology

This book is about teleanalysis, an exploration of teletherapy—psychotherapy by telephone, Voice over Internet Protocol (VoIP), or videoteleconference (VTC). It discusses advantages and disadvantages of psychotherapy and psychoanalysis conducted over the phone and internet.

PART I

TECHNOLOGY, PERSON, AND SOCIETY

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.

In this chapter, I note a few of the diverse facets of the interactions between e-technology and us. I especially explore the impact on self and on intimacy, offering six brief clinical examples. While I note some of its remarkable benefits, I especially focus on some troubling effects. Consider the breadth of phenomena covered by the term social media. Kaplan and Haenlein (2010) state that the term has been applied to an array of technologies including these subtypes:

Social networking (e.g., Facebook, Google+)

Blogs and micro blogs (e.g., Twitter)

Virtual social worlds (e.g., Second Life)

Virtual game worlds (e.g., World of Warcraft)

Content communities (e.g., YouTube)

Collaborative projects (e.g., Wikipedia)

* * *

Overview

The contemporary practice of psychodynamic therapy involves many challenging elements (Stadter, 2012)—one of them is the impact of this technology. As the present volume demonstrates, there are many therapeutic and educational benefits that arise from e-technology but there are also potential dangers. We should study advantages and disadvantages, neither idealising nor demonising technology. From the time of the printing press, technological innovations have raised both extravagant hopes of utopian dimensions and intense dread that they will degrade culture, relationships, and thinking (Carr, 2010; Gopnik, 2011; Powers, 2010).

Some studies indicate that the internet has the positive effect of increasing users’ social networks (e.g., Boase, Horrigan, Wellman & Rainie, 2006). Having an electronic intermediary can reduce social anxiety and anxieties about intimacy, enabling some people to reach out to others more easily (see below). Certainly, e-technology has made communication easy and inexpensive among many people and around the world. Therapists have been able to conduct therapy sessions remotely by either phone or face-to-face through video links. Other studies, however, show a deleterious impact such as a decline in family time of thirty to forty-five minutes for every hour spent on the internet (Nie & Erbring, 2002).

Even the casual observer would conclude that these technologies can powerfully affect those who use them, and now we are beginning to get some indication of that at the neurological level. For example, Small, Moody, Siddarth, and Bookheimer (2009) studied subjects’ brain activity while conducting a Google search. Using brain imaging, an MRI, they compared experienced versus inexperienced internet users. Two findings were particularly interesting. First, the brain activity of the experienced users was much more dispersed than that of the novices. They then had the inexperienced users practise internet searches an hour a day for five days. In the repeat tests, six days after the first tests, the new users’ brain activity was now dispersed like that of the veteran users. Small, Moody, Siddarth, and Bookheimer (2009) argued that the results suggest the human brain is highly sensitive to change through the environment of the internet—in this case after only five hours of practice. Carr’s (2010) review of current research led him to conclude, “When we go online, we enter an environment that promotes cursory reading, hurried and distracted thinking, and superficial learning. It’s possible to think deeply while surfing the Net, just as it’s possible to think shallowly while reading a book, but that’s not the type of thinking the technology encourages and rewards” (pp. 115–116).

These states that Carr notes are unlike those promoted in psychodynamic psychotherapy. The psychodynamic sensibility encourages reflection, patience, the suspension of judgment, the value of ambiguity, of not knowing and of tolerating uncomfortable affective states. As Scharff and Scharff (1998) note, therapists and patients give up the certainty of what they know for the uncertainty of what they do not yet know. This state of mind is also similar to that of “beginner’s mind”, or shoshin, a concept from Zen teaching (Suzuki, 1970) which refers to approaching experience with openness and eagerness, devoid of preconceived notions. Our psychodynamic sensibility can have two competing effects on the practice of therapy. On the one hand, it flies in the face of an e-culture that values speed, certainty, focus on the present, data that has been updated moments ago, and multitasking. On the other hand, it makes psychodynamic therapy a more valuable enterprise, given its evocation of states of mind that are not generally appreciated. One patient noted that she disconnected from her smartphone in our sessions so she could connect more with herself.

Among the many themes that could be addressed in this chapter, I have selected fragmentation of selves and objects and the co-presence of the e-third. The insightful work of Moreno (2010) and Turkle (2004, 2011) have been particularly influential in my thinking. In the following vignettes, all names and screen names are pseudonyms.

* * *

Fragmented selves and objects

Relating in social media environments need not be superficial, affectively dysregulating, or fragmenting but there can be a pull towards this, especially with individuals who have heightened vulnerabilities. This occurs in a variety of ways. With remarkable ease, a person can initiate or end contact, be highly selective, have a multitude of options, impulsively express primitive sexual or aggressive feelings, and keep contact limited (time, distance, anonymity, pseudonyms). Many questions arise. Do people who relate predominantly on the internet not know what they are missing in the real world? What are the neurological differences between contact that is in-person versus contact that is electronically mediated? Goleman (2007), among others, raised the point that internet-mediated relationships do not have the full array of social and emotional cues (unconscious and conscious) that in-person relationships have. How does the absence of part of this array affect the depth of the relationships? How does it affect empathy, aggression, and other behaviours or emotions?

* * *

The e-third as a facilitator of in-person connection

Warren, a twenty-seven-year-old astronomer, was intensely anxious in social situations and avoided them. He had little experience with people outside his family and, until college, was educated at home or in small rural schools. College and graduate school were difficult for him but he had handled them by being a recluse. He began seeing me in weekly therapy because of intense anxiety stimulated by his new job. It required that he work closely as a member of a project team that involved frequent meetings and presentations.

Concurrently he was a member of a weekly online scientific discussion as part of a professional networking site. He enjoyed and looked forward to this regular text-based, theme-focused group. In therapy we examined the nature of his anxiety which included fears of dependency, abandonment, and attack by others. Over a period of two years, he eventually began to meet in-person with two other members who were in the DC area as well, and these meetings subsequently led to friendships beyond their scientific interests. There was a synergistic effect between the therapy and the e-mediated social interactions. The e-third of the online group desensitised him to social interaction in a protected setting and facilitated more developed in-person relationships. In therapy, we worked on moderating his anxiety through understanding it better and through his experiencing it and gradually learning to tolerate it in our weekly face-to-face sessions, as we developed an increasingly intimate relationship.

* * *

The e-third as a narcissistic particle accelerator

Henry Seiden (Hanlon, 2001) used the term narcissistic particle accelerator to describe the internet’s amplification of narcissistic trends by “magnifying the power of otherwise weak and tiny impulses supporting invention, inviting acting out, flattering grandiosity, supporting the spinning out of self-serving and potentially world-shaking scenarios” (p. 567). The next two vignettes illustrate the intensification of part and split aspects of self and its deleterious effects on marriage.

Barry is a married forty-five-year-old father of two who works as a foreman at a manufacturing plant. When I saw him for the first time, he said that he does not respect people who whine about their feelings and that he would never set foot inside a therapist’s office unless his wife forced him to do so—which she did by threatening to leave him. Her complaints involved his generally irritable attitude and daily two hours or more (often much more) on a football website blogging as Ultrafan and engaging in spirited arguments with other fans. He has attended regularly for six months of weekly therapy but he says that he comes only because he is required by “marital law”. His marriage has marginally improved but his connection to me is tenuous.

Barry has a passionate relationship to the website and says that he misses it terribly when he can’t get his “daily dose” of it. He feels more himself there than anywhere else in his life. Barry is respected by a substantial subgroup of the site’s users and his advice is sought by fans around the country. He feels like “the man” when he gets into verbal fights with others on the site and when he exhorts his supporters to “man-up”. He described some of these fights and they are characterised by enraged, contemptuous, obscenity-laced “beatings” of his opponents. He has no empathy for these “stupid assholes”.

Barry’s offline life is very different. He is the only foreman at his plant without at least a community college degree. He believes he is not valued at work, has no chance of ever being promoted and is pessimistic about getting another job. His wife is dissatisfied with him and he feels inept in dealing with his children, aged ten and twelve. He has no friends other than from the website.

* * *

A virtual world and the fragmentation of a marriage

Simulation games take this issue of identity one step further. Two examples are World of Warcraft with 10.3 million subscribers (Cifaldi, 2011, November 8) and Second Life with one million active users (Singularity University, 2011, August 18). These are multiplayer internet games in which the participants interact with one another in virtual environments and the players construct their own identity or identities using avatars which often are very different from the player’s real world identity (for example by choosing to be of a different gender, age, race, or status). An avatar may even be a non-human such as an animal.

Diane, a thirty-eight-year-old nurse practitioner, has seen me for two years of weekly therapy. She was referred by her couple therapist as she became more distressed and hopeless over the state of her marriage. She and her husband, Sam, also thirty-eight, had entered couple therapy with a colleague after he announced that he wanted a divorce. Both of them acknowledged that the marriage had been tense and distant following her miscarriage a year before, but Diane was surprised when Sam made up his mind without discussing it with her. Throughout their marriage, Sam had said repeatedly that he would work hard at repairing the marriage before giving up. Moreover, she had asked him a number of times if anything was wrong between them and he denied it, saying it was due to work stress and how much he was involved with “the game”. The game was an internet simulation game in which he participated with a team of other players from around the world who generally knew each other only as avatars in this virtual world. Notably, in the context of Diane’s miscarriage, an avatar in this game can die but be brought back to life.

Sam found the game to be extraordinarily compelling. Indeed, he would sometimes play for up to ten hours, often at night. As a self-employed consultant, he could set his own hours and would frequently go to bed at six in the morning, sleep until eleven and then meet with clients in the afternoon. Sam and Diane had rarely had sex during the preceding year and were often in bed together only for a few hours a night since he was so involved with the game. The couple therapy foundered and ended after seven months. Both Diane and the couple therapist viewed Sam as not invested in the process, and when conflict arose in the sessions he would emotionally withdraw or angrily walk out. The couple separated after a few months and subsequently divorced. Diane continued her individual work with me.

As their separation agreement was being ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Acknowledgements
• Contributors
• Introduction
• Part I: Technology, Person, and Society
• Part II: Telephone and Internet in Treatment
• Part III: Implications for Training of Psychotherapists and Psychoanalysts
• Appendix Telemental health resources
• Index