Screen Relations

The Limits of Computer-Mediated Psychoanalysis and Psychotherapy

Gillian Isaacs Russell

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780367102807
• eBook ISBN: 9780429918766
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Increased worldwide mobility and easy access to technology means that the use of technological mediation for treatment is being adopted rapidly and uncritically by psychoanalysts and psychoanalytic psychotherapists. Despite claims of functional equivalence between mediated and co-present treatments, there is scant research evidence to advance these assertions. Can an effective therapeutic process occur without physical co-presence? What happens to screen-bound treatment when, as a patient said, there is no potential to "kiss or kick?" Our most intimate relationships, including that of analyst and patient, rely on a significant implicit non-verbal component carrying equal or possibly more weight than the explicit verbal component. How is this finely-nuanced interchange affected by technologically-mediated communication? This book draws on the fields of neuroscience, communication studies, infant observation, cognitive science and human/computer interaction to explore these questions. It finds common ground where these disparate disciplines intersect with psychoanalysis in their definitions of a sense of presence, upon which the sense of self and the experience of the other depends.

PART I

ON THE FRONTIERS

CHAPTER ONE

The western frontier

In 2008, I wound down a psychoanalytic practice of over two decades and moved from the UK to the USA. I exchanged flocks of sheep on the South Downs for flocks of wild turkeys in the Black Hills of South Dakota. I left behind a daughter in her final year of school in Hampshire and a lifetime’s assemblage of dear friends and colleagues. My son was finishing university in Chicago. Because South Dakota was a temporary home, I did not intend to open a practice. Instead, I wanted to continue work on some pieces of speculative fiction I had begun in the UK.

Speculative fiction begins with the question, “What if …” and my what ifs grew from my own grappling with separation from my family, friends, and home territory and my attempts to adjust to a new world and culture. I wondered how it would be if humankind existed spread over remote planets, living in social and cultural isolation, but with advanced technology for instantaneous communication. What if some cultures sanctioned such practices as psychotherapy and others forbade it? What if the concept of the individual and the uniqueness of his/her life story was alien to a culture? What if a society did not recognise the healing potential of human relationships? What if an envoy on a remote planet where psychoanalysis was incomprehensible or prohibited needed help from a therapist on the home planet? My research led me through the history of the Nazi regime to the banning of psychoanalysis as a bourgeois ideology by three generations of Soviet authorities. Then, in one of those serendipitous art–life connections, I came upon an intriguing article about CAPA, the China American Psychoanalytic Alliance. The non-profit organisation was formed to meet the request of Chinese mental health professionals for psychoanalytic psychotherapy training and treatment by providing classes and treatment via Skype, a technological mediation primarily used on computers. They were calling for western psychoanalytic volunteers to supervise, teach, and treat. They wrote about the pleasures and rewards of the work. It was claimed that Skype was incredibly easy to use and secure. “The audio transmission is as good as if we are in the same room. The video also has great clarity” (Kelly & Tabin, 2009). This organisation’s working principles for technologically mediated treatment were, first, just as in traditional analysis, the Skype analysis is based on the quality of the relationship between analyst and analysand and the development of the therapeutic process. Second, that Skype analyses were indistinguishable from traditional analyses. Their evidence of this was provided by “blind” presentations of Chinese computer-mediated cases in western seminars where the faculty and students were unable to differentiate between traditional and mediated transcripts of sessions (Fishkin & Fishkin, 2011; Snyder, 2009).

The prospect of being able to teach and treat enthusiastic students of a different culture from my own remote location was highly intriguing. Skype would solve the dilemma of distance and separation, allowing me to transcend space and time. I was not dependent on a physical consulting room or co-present colleagues. The only instruments I needed were myself and my computer.

At the same time, I was contacted by clinicians I had previously supervised in the UK who wanted to continue to work with me, as well as former patients who needed to process the impact of some recent life events. I downloaded the Skype software and began my exploration of technologically mediated communication.

Until that time, although I was experienced in using a computer, I had never worked remotely. I vaguely remembered reading a paper on video-conferencing in Norway when I was on the editorial board of the British Journal of Psychotherapy over a decade previously. It was a study of a programme designed to solve the shortage of supervisors in rural areas. At the time, London-centric as I was, it had struck me as very much localised to the particular needs of that country. I commenced conducting computer-mediated supervision and treatment, assured by those more experienced than I who affirmed that it was exactly the same as traditional treatment. As long as you maintain an analytic attitude, the process proceeds identically. The transference happens and is analysed, evenly suspended attention to free association is possible, and unconscious communication occurs.

I also began what finally amounted to three years of meetings with peers who also did technologically mediated treatments in China (and elsewhere). These meetings occurred on screen using Skype and although I have now met two of the participants in person, there is one with whom I have yet to shake hands.

Initially, we were preoccupied with cross-cultural issues, the complexities of which represent an entirely separate field of study. As our meetings progressed, we became increasingly aware of the effects of the technology itself, the impact of which was sometimes brought home to us in our own meetings on Skype. Rather than the audio and video being life-like and crystal clear, mediated communication was riven by poor sound, grainy visuals, and frequent interruptions. We became accustomed to “calling back” several times in sessions in order to get a better connection, and learned to turn off the video to increase the bandwidth by using just audio.

We noticed other anomalies. We had curious lapses. It was easy to forget treatment sessions and the times of our peer group meetings. We were likely to bring a cup of tea or glass of water to a session, something we did not do in co-present sessions. We did more talking with our patients about the comparative times and weather. We did more talking in general, as silences were not so easy. We felt less in touch, less intuitively connected. We missed being bodies together—not just with our patients, but with our peer group as well. Colleagues who had begun remote treatments enthusiastically lost their initial energy. The problematic experience of communication in treatment differed from the more straightforward didactic communication in supervision and teaching.

How could it be that we had just assumed that co-present treatment would transport seamlessly into technologically mediated treatment? Perhaps this was partly due to the analytic tradition’s propensity to sideline the body and the significance of the immediate environment. Having done that, the therapeutic process takes place between two minds. The distillation of working mind to mind on screens might be familiar and comfortable for those whose tradition does not include attention to the significance of the nuances of embodied relating. I was not someone who concentrated much on the body in the consulting room. Infant research, as well as studies in neuroscience and non-verbal communication, has progressed rapidly since my training in the 1980s. There are rich new investigations into the significance of the mind–body connection and embodiment in the consulting room (Beebe et al., 2005; Boston Change Process Study Group, 2010; Rustin, 2013; Sletvold, 2014).

At the same time, the importance of the human experience of body-to-body communication is being challenged by the use of technology. Intimacy is mediated as we distance ourselves from the unpredictable sloppiness of relationships. Simulation offers an illusion of authentic connection, and we lose the gift of the genuine closeness that takes time and effort (Carr, 2011; Turkle, 2011). “The devaluation of the human body and, by extension, also body-to-body communication cannot be stopped by simply celebrating body-to-body communication. The underlying reality is that our increasingly complex society is weakening the possibility for the modern-day individual to communicate with others” (Fortunati, 2005). It is ironic and disconcerting that psychoanalysts and psychoanalytic psychotherapists are embracing screen relations (Essig, 2012a, 2015) at the very time when their disturbing effects on our relationships are being called to our attention (Carr, 2011; Turkle, 2011).

If we opt to use new tools, we need to know the nature of those tools and how those tools change us. We need to understand the gains and losses and then decide, case by case, if the trade-off is worth it. What happens when we reduce our therapeutic relationships to two dimensions bound by a screen? “You may find talking into a camera difficult at first,” writes an analyst about using Skype on his website, “but in a few sessions you get used to it …” What does that mean, “get used to it”? Because we are wired to relate, do we unconsciously adjust to a degraded form of communication? What are we settling for? “I fear that we are beginning to design ourselves to suit our digital models of us, and I worry about a leaching of empathy and humanity in that process,” says Lanier (2011, p. 39), computer scientist and pioneer in the field of virtual reality, “… can you tell how far you’ve let your sense of personhood degrade in order to make the illusion work for you?” Although it is far beyond the scope of this book to exa mine, it is hard to deny, in general terms, that we are forgetting on both personal and community levels that mediated modes of communication are generally more limited than co-present communication.

I set out to understand what happens when we practise technologically mediated treatment. I wondered how it works, what were its uses, and what were its limitations. These questions took me into realms where I had not ventured before, such as informatics and communication, human–computer studies, and neuroscience. Determining what happens on the screen made me explore what we think happens in the consulting room. Even this contentious subject is far from settled. I talked to psychoanalysts, psychoanalytic psychotherapists, supervisees, students, and patients in interviews and dis cussion groups, some transcribed from audio recordings. I learned much from lively and thoughtful exchanges with colleagues. I have let people speak directly in this book, but disguised them to preserve their confidentiality and, where applicable, obtained permission to quote them. In a few instances, people gave me permission to identify them. With regard to the term Skype, many use it as a generic term when they are referring to technologically mediated communication. There are, in fact, other free platforms such as FaceTime and ooVoo, with varying degrees of security. The commercial, paid-for video-conferencing services are more technologically robust, but prohibitively expensive for an independent practitioner.

I use the terms psychoanalysis and psychoanalytic psychotherapy to refer to the therapeutic process “which involves frustration and gratification, insight and relationship, autonomy and dependence, agency and communion, internal and external change, structural and symptom or behavioral change” (Aron, 2009, p. 665). The practitioners of this process, who have had their own intensive trainings and per sonal analyses, I refer to interchangeably as analysts/therapists or psychoanalysts/psychoanalytic psychotherapists.

By way of clarification, I am not a Luddite. Like most others in the twenty-first century, I use the computer for myriad purposes, including writing this book and talking with my family in various parts of the world. I even conducted part of a courtship relying on technology. I am not saying that technologically mediated treatment should never be used. I have used and do use technology for teaching, supervision, and some treatment. When I refer to computer-mediated communication, I am considering the level of technological development we have available right now.

This book was written because of a dawning understanding that what was happening between me and my patients in mediated treatments was not the same as the co-present process in the consulting room. I wanted to encourage asking questions that were not being asked. In the process, I learnt that we cannot use technological treatments without knowing and acknowledging their limitations, as well as their positive aspects. We need to know the differences they have from co-present treatments and not assume they are identical. I have tried to begin an articulation of the particulars of this difference. When I initiated a dialogue with my colleagues, it was striking that many of us seem to have sleepwalked into the use of technology for treatment. The questions I asked them, as I grappled with them myself, were like a wake-up call. They told me repeatedly that they had not thought through those issues before and were so glad to do so now. As is so often the case, more questions have been raised in the undertaking.

Psychoanalysts are not exempt from the very human desires to abolish distance, avoid separation, bypass frustration, have ease without commitment, and jettison inconvenient bodies with their sensory and physical constraints in search of new modes of existence. The profession is just as prone to respond to the seductions of technology as anyone else, with technological advances creating new human “needs” that then eventually lead to increased consumer demand (Blascovich & Bailenson, 2011).

As we are still a long way from a complete understanding of the role and social significance of mediated communication, we are often tempted to gloss over the unknowns by singing hymns in praise of technology, or even setting up technology as the last great ideology. (Fortunati, 2005, p. 58)

The apparent solution to dislocation is constant connection. Remaining “always on” not only affects the “tethered” generation of children, who never learn a sense of autonomy, resourcefulness, or privacy, but also the older generation who, plagued by anxiety, are unable to let go and trust that their children will survive. Increased and indiscriminate use of technological mediation leads to impoverished relationships, because it is more limited than bodies being together. We then use technology further “to patch up the rips and holes in the net of our social relations—‘a poor substitute is better than nothing’” (Fortunati, 2005, p. 57). We must not lose the sense of what embodied human relating is. An Israeli psychoanalyst, Shmuel Erlich, says that technologically mediated treatment is so routine in China that he met a woman in Beijing “who was astonished that there was some other kind of analysis” (Osnos, 2011). Just as we do not want our children to grow up believing that the convenient substitute of mediated communication is equivalent to embodied communication, so we must not lead our patients to believe that technologically simulated treatment is the equivalent of co-present psychoanalysis.

While I was starting to ask questions about what exactly we are doing when we use technological mediation for treatment, a psychoanalytic land rush towards mediated communication was beginning, fuelled by enchantment with technology, fear of professional obsolescence, and economic anxiety. Psychotherapists are vying to stake a claim in the “new frontier” before it has even been properly explored or mapped. How can we square confining ourselves to two dimensions on a static screen, when it is the essential humanity of the psychoanalytic process that we are offering as an instrument of change? We are not talking heads. Our mental processes emerge from our situation in our bodies and our involvement in a shared environment. It is ironic that some therapists turn to technological mediation as a first choice and without reflection, when what we are there to do is help patients discover what prevents them from feeling fully alive. How could we ever embrace the attitude that “a poor substitute is better than nothing” except in the case of triage or when there is no other choice?

I never finished writing the speculative fiction. Instead, what I encountered was an emerging reality far more fascinating that anything I could imagine. I discovered that we are living and practising in a world of speculative non-fiction. Events in the present-day world have given rise to a series of “What ifs” that need urgent clarification in the here-and-now. My colleagues started to ask questions, patients ask questions, trainees ask questions. Those questions can only begin to be answered if we allow ourselves to engage with fields other than psychoanalysis. If we add technology to the psychoanalytic mix, we need to ask the people who have worked in communication studies, informatics, computer science, and technology long before we entered the mediated scene what impact this addition has on the intense nature of close relationships. These are the questions with which this book is concerned.

CHAPTER TWO

Exploring the speculative non-fiction digital frontier

Conversations with clinicians and patients

I began my conversations with clinicians because I felt in the dark using technology for treatment. I was not in the dark technologically; I could manage the hardware and software. I had been using a computer for many things, including mediated communication, for some years. I was in the dark in the midst of the sessions. Something unexpected and different was happening. I felt unable to use my customary analytic skills. This feeling did not happen all at once, it happened very gradually over time as I continued to “see” patients mediated by a computer. I thought that perhaps my colleagues, some of whom had been doing technologically mediated treatment far longer than I had, knew something I did not. Maybe they could teach me what they had learnt about distance treatment. Maybe we could be of some support to each other.

What I discovered consistently was that my colleagues were as eager to talk about their experiences of computer-mediated treatment as I was. They said repeatedly that they felt they had never done so thoroughly before. Like myself, most of them had dived into computer-mediated psychoanalysis or psychoanalytic psychotherapy without knowing anything about the potential gains, losses, or differences in comparison to co-present treatment. Like myself, though venturing into new territory, they approached the sessions as if they were duplicates of those in a shared environment.

Yet, all my colleagues noted differences, some subtle, some glaring, in the experience of computer-mediated sessions. Significantly, most—but not all—noticed changes in their own behaviour, as compared to co-present sessions. Even for those who did not notice any change, it emerged in conversation that behaviour did frequently shift to the uncharacteristic, from sipping a cup of tea during a session to seeing patients from multiple environments, such as home, a home office, the consulting room, and/or a hotel.

Practitioners tell me they see patients using video-conferencing technology for a variety of reasons. Some work with patients who live in a geographical location where there is no available qualified practitioner. They commence a treatment never having met their patients face-to-face. Some continue to meet with patients they had been seeing co-presently after either the therapist or the patient relocated permanently. Others use computer mediation to see patients who could not get to the consulting room because of a chronic or acute illness or disability. Computer mediation is used as an adjunct to co-present treatment during patients’ family crises which preclude an office visit and for patients whose work or education requires intermittent travel. One psychoanalyst was affected by a natural disaster that rendered him temporarily homeless and without a consulting room.

Patients, too, are eager to talk about their mediated sessions. Like my colleagues, they are inspired to...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• ACKNOWLEDGEMENTS
• ABOUT THE AUTHOR
• SERIES EDITOR’S PREFACE
• FOREWORD
• INTRODUCTION
• PART I ON THE FRONTIERS
• PART II IN THE CONSULTING ROOM AND THE RESEARCH LABORATORY
• PART III ON THE SCREEN
• PART IV MAKING A PLACE FOR SCREEN RELATIONS
• REFERENCES
• INDEX