Abstract
Teleanalysis—remote psychoanalysis by telephone, voice over internet protocol (VoIP), or videoteleconference (VTC)—has been thought of as a distortion of the frame that cannot support authentic analytic process. Yet it can augment continuity, permit optimum frequency of analytic sessions for in-depth analytic work, and enable outreach to analysands in areas far from specialized psychoanalytic centers. Theoretical arguments against teleanalysis are presented and countered and its advantages and disadvantages discussed. Vignettes of analytic process from teleanalytic sessions are presented, and indications, contraindications, and ethical concerns are addressed. The aim is to provide material from which to judge the authenticity of analytic process supported by technology.
As patients increasingly move or travel to distant locations for work, and as those who live far from analytic centers learn of the value of psychoanalysis, analysts are being asked to conduct analysis over the telephone or internet. Can psychoanalysis accommodate these requests? Many questions arise (Scharff 2010). Can psychoanalysis adapt as concepts of time and space change with the increased mobility of the global economy? Can psychoanalysis be effective for an analysand whose body cannot be present in the analyst’s consulting room? Can there be effective affective attunement, an appreciation of resistance, and work with transference-countertransference when treatment is supported by technology? Is deep analytic process possible in this situation? Are psychoanalysts willing to adapt established models of treatment?
Some analysts are already experimenting with use of the telephone and the internet in their conduct of psychoanalysis and analytic psychotherapy (Aronson 2000a,b; Scharff in press; Lemma and Caparrotta in press). The American Psychoanalytic Association has reported that of 859 respondents to the 2011 Psychoanalytic Professional Activities Benchmarking Study, 28 percent use the phone and 9 percent use Skype for psychotherapy, 9 percent use the telephone and 4 percent use Skype (the proprietary name of a Voice over Internet Protocol) for psychoanalysis of patients at a distance. Over ten years ago, Richards and Goldberg (2001) found that of 120 psychologists surveyed, 83 percent had conducted telephone therapy in the past two years. In a survey sent electronically to 140 analysts from seven Latin American institutes, only 60 questionnaires were deliverable, and of the 60 recipients 32 responded. Fifty percent of the responders thought it not possible to do psychoanalysis by telephone, while 34 percent considered it possible (Estrada 2009). The fact that the sample size was so small keeps these results from being significant across the IPA membership; they indicate merely a trend. That so many e-mail addresses were invalid or no longer current indicates how much the analytic community needs to develop in the area of technology.
The practice of technology-assisted psychoanalysis in the United States began in the 1950s (Saul 1951); though with each ensuing decade its incidence has increased, it is underreported since its use remains controversial. Nevertheless, made aware of the availability of teletherapy, Warren Procci, then president of the American Psychoanalytic Association, urged members in a 2011 e-mail to “consider this . . . a serious issue”; he suspected that “the use of this mechanism will only increase as technology continues to improve.” Not enough is yet known about the clinical effectiveness of teleanalysis, and quantitative research has not yet been undertaken, although plans are under way: The China America Psychoanalytic Alliance will undertake a quantitative study (Sherwood Waldron, personal communication 2012); the American Psychoanalytic Association has established a group to report on teleanalysis; and the International Psychoanalytical Association is considering its position on the clinical effectiveness of teleanalysis in training (Jorge Canestri, personal communication 2012).
Use of The Telephone and The Internet in Psychoanalysis
Psychoanalysts in the United States routinely use the telephone to screen requests for treatment, arrange appointments, and make referrals, as the most usual, practical, and efficient way of conducting business. Through tone of voice, manner, and ease of communication, this telephone contact conveys an impression of the analyst and the potential analysand (Zalusky 2000). The experience of the prospective analyst and patient during the initial telephone call includes all the elements—resistance, defensive functioning, alliance, transference-countertransference—that will color the subsequent analytic relationship, or end it before it begins. Analysts who do use the telephone to initiate the therapeutic contact have for the most part discouraged its use between sessions and eschew telecommunication as a legitimate setting for the conduct of psychotherapy or psychoanalysis.
Nevertheless, some analysts have been conducting teleanalysis over the telephone and, more recently, the internet. (A landline with a headset is more secure than a cellphone, and the sound of the voice is less tinny.) Since 2003, remote analysis has included audiovisual transmission, using a web camera and microphone with a Voice over Internet Protocol, or VoIP (most commonly Skype, a free service). At the appointed hour for the session, the analysand calls up the analyst’s nternet address, and the analyst accepts the call. The analysand’s camera is already trained on the couch. The analyst then sees the analysand lie down, listens to the material, and observes body movements as the session proceeds. When the time is up, the analyst disconnects from the call. Computer to computer, VoIP delivers clear speech directly via a headset to both ears, which means the voice is vivid and immediate, even closer than in the conventional office setting. However, the technical benefits of VoIP come with disadvantages too. Dropped calls, extraneous noise on the line, and poor reception literally break the frame and interrupt connection to the analyst from time to time. Such interruptions to the process may be frustrating to both parties. Another, quite different disadvantage is that having the analyst’s voice “right in the ear” may be experienced by the patient as unbearably tantalizing.
Security is a concern. VoIP communication is broken into bundles that are not reassembled until they reach the receiver’s computer (packet switching), which seems good for confidentiality. Indeed, Snyder (2011) holds that Skype computer-to-computer is totally secure and has never been hacked. However, Maheu (2012) holds that Skype, being a consumer-grade platform, cannot be assumed to be secure: it does not expose its encryption to independent testing for verification, does not guarantee HIPAA compliance, and therefore cannot absolutely protect confidentiality (see also Scharff 2012b). Maheu thinks that videoteleconferencing service purchased from a company with a medical-grade platform to ensure confidentiality and reliability is the most secure technology; it is, however, a stretch for the solo practitioner who analyzes only one or two patients on the telephone or internet.
Arguments Against Use of The Telephone in Psychoanalysis
A number of analysts have argued that analytic process is not possible in teleanalysis. Yamin Habib (2003) believes that the change of setting undermines the very essence of psychoanalysis: it introduces a third party, violates neutrality and abstinence, and “tends to favor action rather than reflection” (p. 27). The telephone, he argues, distorts vocal inflection, creates a spectral relationship with a part-object, and interferes with the reception of unconscious communication so essential to analytic process (Brainsky 2003). Argentieri and Mehler (2003) believe that the telephone “is simply not compatible with a psychoanalytic process” because of “sensorial deprivation” and “loss of the holding containment given by the presence of the other” (p. 18). Since the body of the analysand is not in the same room as the analyst, there is no personal connection, no nonverbal communication to work with, no odor, and no atmosphere. They object that the analyst is not in control of the setting. When an analysis is interrupted when the analysand must relocate, or when the analyst becomes unable to travel to the office, the analytic pair may resort to teleanalysis. Yamin Habib (2003) sees the offer of teleanalysis to maintain continuity in such situations as indulgent, gratifying of infantile needs, and defensive. When the analyst offers, or the patient successfully pleads for, teleanalysis, both parties avoid analyzing resistance, interpreting internal reasons for the break, and, when an end is inevitable, mourning the loss of an incomplete treatment. Those who argue against teleanalysis see it as a break in the frame and in the conduct of analysis. Argentieri and Mehler (2003) write that analytic process cannot occur on the telephone, though they concede that psychotherapy over the phone may be possible. Clinical example 1 tends to support their view. I will present arguments to counter it after the following examples of sessions when the offer of teleanalysis does not seem effective.
Clinical Example 1
A woman in traditional analysis had to be out of town on a short vacation. I agreed to her request for a session on the phone. She secured the time and place, but we were not able to re-create an analytic atmosphere. We both recognized when she returned for her next session in person that the session on the telephone had felt as if she were chatting to a friend and looking for things to say to fill up the time. Actually, it was an exaggeration of the way in which some of her in-person sessions seemed unsatisfactory, pointing to a feeling of emptiness and lack of worth that undermined her pleasure and productivity. The difference between the session on the telephone and the one in person reflected an alternation between the depressed and creative aspects of this woman. But had the session on the telephone been recorded, the audiotaped material would have supported the idea that analysis is not possible on the phone.
Clinical Example 2
A man who valued his in-person analysis disdained teleanalysis. He usually attended regularly and was always on time, but he had professional and child care responsibilities that meant that occasionally he could not attend a session. He regretted these interruptions to his analysis, and yet he declined sessions on the telephone when they were offered. He preferred to pay for missed sessions and take the loss than experiment with another way of doing things. Familiar with the psychoanalytic literature, he said that teleanalysis was not the right way to do analysis. I accepted his choice as his prerogative, but I also looked for the transference resistance in it. His disdain was a new edition of his attitude toward his parents, whose parenting and money management were too rigid, and his wife, whose money management and child-rearing were too loose. None of us were the right way to be, a projection of his feeling about himself as the wrong kind of child and husband.
Arguments in Favor of Teleanalysis
Those who do practice teleanalysis experience the psychological and technical difficulties of relating across a distance but find that these stimulate the patient’s reactions to the technology and to the analyst’s provision of the space. These reactions reveal unconscious dynamic factors and deliver them into the transference as would reactions to difficulties experienced in the in-person setting, as clinical example 5 will show. Analysts who have pioneered use of the telephone, the videophone, and the headset have shown how erotic, negative, or paranoid transference can ripen or be intensified, openly or hidden from view, as in in-person sessions, and can be interpreted effectively (Saul 1951; Leffert 2003; Lindon 2000; Aronson 2000a,b; Zalusky 2005; Scharff 2012a; Symington 2009). Rodriguez de la Sierra (2003) sees the provision of teleanalysis for continuity not as a gratification of infantile needs for attachment but as “an appropriate adaptive defence against separation anxiety” (p. 21). Mirkin (2011) found that telephone analysis fostered the expression of affect, reflection, and exploration of defense because “continuity fosters intensity and distance and protects from impulsive action” (p. 669). Sachs (2003) cautions that the choice of conducting teleanalysis should be evaluated in each case and that no analysis can be conducted exclusively on the telephone: the analytic pair must meet in person from time to time. With that caveat, with which I agree, Sachs concludes that the selective use of teleanalysis “promises to increase the range and value of psychoanalysis” (p. 29). Yet even proponents of teleanalysis have tended until now to view teleanalysis overcautiously as second best, a therapeutic compromise, or merely better than nothing (Lindon 2000; Benson, Rowntree, and Singer 2001; Zalusky 1998), views that diminish the value of teleanalysis (Sachs 2003). But even Yamin Habib (2003), who regards teleanalysis as an inauthentic form of analysis and recommends against importing the telephone as a third party, recognizes that in the near future “this recommendation may cease to apply, so that there could then be two modes of therapy, one with and one without actual presence” (p. 25). By now, more experience of telephone or internet analysis having accumulated, we know more about its liabilities, and have more evidence of its clinical effectiveness (Carlino 2011; Lemma and Caparrotta in press; Scharff 2012a,b, in press).
Even so, there is as yet not enough experience with teleanalysis to arrive at consensus regarding its effectiveness or its indications and contraindications. Admittedly, not enough is known about the level of security that analysis over the telephone or internet can guarantee. Nevertheless, the analytic pair may decide that teleanalysis is better than no analysis. In that case, analysands should be fully apprised of these concerns so they can give informed consent. Teleanalysts should subject their work to process and review by consulting with colleagues who study the effectiveness of teleanalysis, should meet licensure requirements, and should use review to develop and maintain the appropriate ethical stance.
Differences and Similarities in Tele-And Traditional Analysis
The argument has been presented that teleanalysis breaks the frame and is not really analysis at all. Against this, I argue that teleanalysis, like traditional analysis, values the standard psychoanalytic tenets: a firm frame, a nondirective stance, free association, unconscious communication, analysis of resistance, dreams, and transference-countertransference, interpretation, listening to how the patient receives the interpretation, more interpretation, transformation, working through, and the development of a self-analytic function. Hanly (2007) supports this view, finding in his experience of telephone analysis that responsive holding, witnessing, and interpretive functions could be sustained, and that free association and the development and expression of paternal and maternal transferences were not compromised. Argentine colleagues agree that telephone analysis is similar to traditional analysis in using the analyst’s suspended attention to free association, working with the unconscious and its derivatives and repressed childhood sexuality, and analyzing dreams and transference (Aryan et al. 2009), and they provide illustrations (Lutenberg 2011b). With colleagues in close process study of analytic process in in-person and telephone sessions with the same patient, we cannot reliably distinguish one setting from the other, unless there happens to have been a specific reference to the call.
Analysis using the telephone does not feel the same as analysis with the analysand in the consulting room. And yet it is similar in providing the same shift from established social settings that in-person use of the couch offers. Both are technical accoutrements that deemphasize some elements of the nonverbal environment while emphasizing others (Leffert 2003). Like the couch, the telephone limits visual cues and gaze interaction and thereby frees the analyst’s capacity for reverie (Richards 2003). The analyst sitting behind the analysand out of sight frequently closes his eyes to listen with the third ear (Hanly 2007) in order to “turn his own unconscious like a receptive organ towards the transmitting unconscious of the patient” (Freud 1912, p. 115). The analyst cannot see the analysand’s body and, a fortiori, cannot read the body language, but the minds of the analytic pair still interact and, unseen, so do their bodies.
Some analysands prefer using a webcam so they can have a visual connection to the analyst at the beginning and end of each session, and they are comfortable or gratified to imagine the analyst looking at them, as they might be in traditional analysis. Some analysands, however, reject any use of the webcam: they do not want the analyst to see them when they cannot see the analyst; but this is the same resistance they would feel lying on the couch in the analyst’s office. Some analysts reject the option of analysis on the telephone or VoIP; they regard it as a parameter, the use of which, as a break with tradition, might meet with disapproval and loss of affiliation with colleagues, thereby weakening their sense of secure analytic identity. The threat of this anxious and guilty sensation is what creates the commonly held view (despite a lack of research data) that in-person sessions are so far superior that they should under no circumstances be replaced by teleanalytic sessions, a view held mainly by those who have not tried to conduct teleanalysis.
The analyst who conducts sessions using VoIP with webcams can see the analysand’s body movements as he would in an in-person analysis. Even so, analysis with a visual image is more similar to telephone analysis than to in-person analysis because the analytic pair do not meet in the analyst’s office, the analysand is not seen as clearly as in person, and accompanying odors are not actually there (though the analyst may nevertheless imagine an odor in association to words and silences). The point is that there is a loss of visual acuity that must be recognized. Those who do teleanalysis need to recognize that loss of the fullness of the experience of in-person psychoanalysis, and mourn it. Then patient and analyst are freed to make the best use of teleanalysis.
In sum, teleanalysis differs from traditional analysis in that the patient is not in the same room as the analyst during each session. The worry is that “intensity of unconscious experience in the transference, fundamental for anyone undergoing analysis, does not seem possible to us without the physical presence of analyst and analysand in the session” (Garcia 2011). But those who do conduct analysis on the telephone or VoIP find that analyst and analysand create and sustain a mental representation of the other in fantasy, and that in this way a new type of analytic process develops (Zalusky 2003). For those lacking experience with teleanalysis, the major concerns are with the nature of the setting and the capacity to sustain analytic process through reliable unconscious communication (Scharff 2012a).
The Setting
In contrast to in-person analysis, in teleanalysis there is a difference in the space and time of the setting for each participant (Aryan et al. 2009). But the two ways of conducting an analysis are similar in that each requires a circumscribed setting. The teleanalyst respects the frame of the treatment, requiring regular frequency and a set time limit for sessions, as well as agreed-on periods of in-person sessions. In teleanalysis, analyst and analysand do not share a physical space set up by the analyst. The analysand does not enter the analyst’s space. Instead the analysand is responsible for setting up a stable environment conducive to contemplation. The analysand calls the analyst and the analyst takes the call, much as he opens the door when the patient arrives in person at the appointed time. As they see each other on the screen or say hello on the phone, analyst and analysand enter each other’s space. The analysand lies down. The analytic pair create a transitional space between their two settings. Many analysands describe in detail their physical setting, including the room, the furniture, the quality of the light, the weather, and the location of family members and pets (Chodorow 2004). They vary as much in their ability to inhabit this virtual space as those in traditional analysis vary in their capacity for free association and unconscious communication.
Clinical Example 3
A woman psychotherapist who began treatment with her analyst in person changed to telephone sessions when her analyst transferred to an urban center. The woman arranged a space for her treatment at her new place of residence. At first she experienced grief over this arrangement. She missed the physical space of the analyst’s office, the ritual of the waiting room, and the visual contact with her analyst. Later she realized that enjoying those visual aspects had not left as much room for her imagination. Explaining further why she came to prefer their telephone sessions, she wrote, “I had the freedom to look inward at the objects that flickered across the screen of my mind. I needed all those phases: the initial holding, the grief over losing it, and the increased enjoyment of psychic space that allowed me, especially during the termination phase, to internalize my analytic mother” (Michelle Kwintner, personal communication 2009).
In teleanalysis, choice of setting expresses the personality much as body movement and clothing style do in traditional analysis. At times the analysand’s choice of setting reflects aspects of bodily experience waiting to be perceived, as the following example of a session using VoIP with webcams shows.
Clinical Example 4
A depressed professional woman in the opening phase of her in-person analysis transferred to a remote location. She arranged her teleanalysis in a room at her home where she worked half-time because she lacked the energy to go to her office and work full-time. Using VoIP and a webcam, she gave the camera a view of her on the couch in front of glass doors that reflected light and made it hard for the analyst to see her clearly on the monitor. Her analyst had a worrisome image of her as a tiny, ghostly creature lying in a glass box. Analyzing this usefully gave access to her history as a dangerously premature infant who had been raised for a month in an incubator. She always knew this as a fact of her history, but she had not experienced it until this session. Once the full impact of this on her mother-infant attachment and on her continued development was understood and mourned, she became stronger and capable of full-time work, and transferred her treatment setting to her well-lit office, a setting in which she looked much more substantial (Varela 2011).
Unconscious Communication without Nonverbal Cues
The main reason given for rejecting teleanalysis as a viable form of treatment is that the body of the analysand is not present in the room with the analyst, and that, at least on the phone, the contact is exclusively auditory. Against this view, Fink (2007), who holds that work with words spoken aloud in sessions is the only thing that makes analysis effective, cites Lacan’s claim (2006) that “psychoanalysis has but one medium: the patient’s speech” (p. 247). But that dictum overlooks the affective tonality and rhythm of the voice. Brainsky (2003) does acknowledge the importance of tone and timbre, but then diminishes the value of vocal communication by seeing voice as a series of split-off idealized and persecutory part-objects (p. 23). Of course the use of the telephone relies on speech and analytic listening as the primary mode of exchange in psychoanalysis, but the analyst is not actually reduced to working with a single channel of perception. Auditory input recruits other senses. The analyst’s imagination senses the emotional atmosphere and ranges freely among all the senses, as it does in traditional analysis. Deep unconscious communication and affective attunement support analytic work in teleanalysis, even as they do in traditional analysis.
Clinical Example 5
Ms. A., now in analysis with me, had had previous in-person psychotherapy in her home town with a female psychotherapist who framed interpretations in oedipal terms. In that earlier treatment, my analysand had revisited childhood memories, stabilized her mood, and worked on her adult development. Though she had received considerable benefit at that time, a feeling of dread persisted daily. Feeling she needed analysis to be free of that continuing anxiety, and with no psychoanalyst in her immediate area, she traveled to meet me and establish an analytic way of working in person before continuing in telephone analysis.
Ms. A. had been talking about loneliness, neglect, and abuse during her childhood. One day in a telephone session she told me she had felt so miserable and desolate as a young child that she wished she would die. She fell silent. I had a sensation of her dropping out of contact. On an earlier occasion she had talked of a balcony overlooking a patio where she used to play. As this image came back to me, I said, “I see you all alone on a balcony, desolate, looking over the edge, longing to be held and imagining dropping.” She cried with relief, and told me that in her silence she had been remembering looking over the edge to the ground below where her relatives might be upset to find her shattered if she had jumped, as she often wanted to. But she had never told them, and they never noticed her misery. She said that for the first time, someone was there with her on the balcony. She often referred back to this moment in her analysis. She said that when my comment connected with her memory of her suicidal fantasy, she felt both understood and held safe. She said later, “It was the coincidence of your voice and my thinking that meant so much to me.” Some months later, she said, “I have gone away from that balcony, and it is not a dangerous place anymore.”
From that time on, although the analysand still felt anxious on occasion, she no longer suffered from a daily sense of dread. In a termination session, looking back on this experience, she said that the balcony session had been a transformative moment.
We are taught that nonverbal body language provides the harmonics of language and human interaction. Obviously the analyst lacks those cues on the phone. Certainly without them the analyst on the phone has lost one way of establishing a treatment relationship and of receiving communication and feedback after interpretations, but this example shows that nonverbal communication can occur without vision and bodily presence. Once we let go of the ideal of traditional analysis, we are free to appreciate what is possible in terms of unconscious communication via the transmission of sound alone.
Clinical Example 6
Mr. M., who was completing his analysis on the telephone, had been telling what he could remember of a traumatic rape as a boy at the mercy of a pederast with a knife. I felt the full impact of what he had been through and the horror of recalling it. Upset by what he remembered and could not remember, his body reacted to the stress of this process by producing what he described as a rash on his ankles. His mind reacted with a dream in which he saw what he described as “many small cuts” on his leg. This might have meant that he felt injured or had been literally scratched with nails or a knife. But the image that came into my mind was of an injury more like a graze, with scratches going vertically and horizontally. I had a frightened, helpless feeling of dread, my mind’s eye looking at the broken skin. What I saw there did not fit the words he had used to describe the rash on his actual leg or the cuts in the dream.
I struggled with this persistent image. If I shared it, I might interrupt the flow of Mr. M.’s associations; worse, I might be leading the flow of associations, like an attorney leading a witness. But his associations were stuck. As Mr. M. remained unable to proceed, I decided to speak. I said that the image had entered my mind as a graze or, more specifically, a fabric burn. Did he have any idea why I might have that image? He immediately realized that these were marks from the ropes with which he had been tied up to prevent his escape, an additional source of trauma that he had forgotten.
Mr. M.’s unconsciously determined, verbally expressed memory had obscured the source of the marks on his skin, but his unconscious had conveyed it to my unconscious in eidetic form. Unconscious communication can occur via auditory and sensory routes, as well as via visual perception and interaction. Language is embodied in the resonating sensorimotor system. A purely auditory communication on the telephone provokes a visual image in the listener. The feeling of dread at receiving the image and the unfamiliarity of the experience fit with two elements of Freud’s definition of the uncanny (Freud 1919). I prefer to think of it as unconscious interpersonal communication (Scharff and Scharff 2011).
Institutional and Personal Resistance to Teleanalysis
The offer of teleanalysis may be seen as a resistance to facing the reality of separation and loss, a gratification of the wish for a special accommodation. But failure to offer or accept teleanalytic sessions can also be seen as resistance to the reality of the analysand’s circumstances and to the analyst’s reality of losing visual connection. It was Freud who alerted us to the possibility that “anxiety about one’s eyes, the fear of going blind, is often enough a substitute for the dread of being castrated” (Freud 1919, p. 231).
Personal resistance to an innovation like teleanalysis is cemented by the reactions of our colleagues and professional associations. Some of us have felt that offering teletherapy is a narcissistic choice, as if there is but one person who can be of help to the patient. Certainly freedom of choice of referral is essential. But surely continuity of care is an equally compelling value. Why waste years of building trust, sharing history, making links, formulating hypotheses, developing an effective analytic relationship, and establishing the transference-countertransference dialectic? Why should the analysand have to start over, when technology is available to support the continuation of treatment to its conclusion? Why should analysands who live in underserved areas be denied treatment?
Of those of us who try analysis on the telephone or over the internet, many are initially more ill at ease than the patient (Leffert 2003). For instance, Hanly (2007) was asked to continue his patient’s analysis on the telephone, but having had no experience with this, he was worried the technology would be a distancing tool; he was afraid the patient might feel abandoned by the lack of his presence and would return to a state of anxiety. Agreeing reluctantly to the patient’s request, Hanly was in time reassured by his experience conducting teleanalysis. His account of it shows that analysis can be done effectively on the telephone. Teleanalysis allows us to “put the welfare of the patient above the demand for procedural conformity” (Sachs 2003, p. 28).
Indications and Contraindications
Teleanalysis is indicated for those at a distance, with no access to local help, or with too much visibility in their own community. Teleanalysis is indicated to maintain continuity for those who must travel for work, transfer to another college, or are unable to get to the office because of a phobia or a medical condition such as undergoing a kidney transplant. Teleanalysis could be a useful accommodation for analysts who are convalescing, retiring, or alternating between two homes to be near grandchildren. Teleanalysis may come to be a matter of preference for a young generation who routinely conduct much of their relationship life online.
Teleanalysis is contraindicated for pathology such as addiction, psychopathy, and suicidality when the degree of potential harm cannot be contained, and yet in some cases even these may be manageable if the analytic relationship is strong and if a trusted local psychiatrist is available for emergency care or adjunctive medication. Some believe that teleanalysis is impossible in psychosis, but examples of psychotic elements being worked with have been presented by Lutenberg (2011a,b,c) and Symington (2009). Teenagers are comfortable with teleanalysis, but I know of no instances where it was workable with a child, primarily because children need to play in the presence of the therapist. A definite contraindication is severe deafness or discomfort with the modality in either analyst or analysand. A possible contraindication is access to a local analyst. Teleanalysis is contraindicated where the analysand is a “person of interest” to the government and where the line is not secure. It is contraindicated where it is objected to by the analysand’s country, is illegal in either country, or taxes are not being paid (Aryan and Carlino 2009).
A major inhibiting factor is the state-by-state control of licensure (Benson, Rowntree, and Singer 2001). Professional associations all recommend that teleanalysts be licensed in the state where they work and be held to the licensure requirements of the states in which their patients are located. States govern medical, social work, and psychology licenses under which analysts may practice, and vary in their requirements for licensure and in their responses to requests for exceptional permission or temporary or restricted licenses to practice. For instance, California will not allow insurance reimbursement for teletherapy. Only two states, Vermont and New York, license psychoanalysts specifically. Because disputes may arise over the varying licensure requirements of the states, the American Telemedicine Association is lobbying for a federal license (Linkous 2012). Rules and regulations are being rewritten, and new practice guidelines are being issued by the various mental health professions to adapt to the problems and benefits of technology and its effects on lifestyle and mental health service delivery.
Rules and regulations are intended to protect both patient and analyst, but they create a dilemma where the authority to practice is in conflict with the ethical principle of continuity of care.
Clinical Example 7
A bright young woman with ADHD and executive function disorder, a history of drug abuse, and extreme family stress had been in rehab for the second time. She had maintained no connection to any of her counselors or therapists. After discharge she began combined and concurrent family therapy and individual psychoanalysis, and for the first time began to regulate her life. She was accepted into a college that could develop her considerable strengths and support her weaknesses. But this college was in another state. Aware of that state’s proscription of teletherapy, the difficulty of obtaining licensure there, and knowing of a good therapist in the college town, her analyst gave the patient a referral. The patient did not contact the new analyst, however, and when a family crisis occurred she fell apart and had to return home and reenter treatment. She settled down again, enrolled in a local college that was not as good a match for her, and eventually returned to her college in the other state. The analyst would have liked to maintain continuity but could not do so because of the restrictions of licensing laws, even though his decision might lead to another breakdown for the patient.
Distance Analysis without Use of The Telephone or Internet
There are other options for offering analysis to patients at a distance: condensed analysis and shuttle analysis. In condensed analysis, the analysand has blocks of intense treatment at intervals when the analyand travels to the analyst’s location. In shuttle analysis, the analyst travels to see a group of analysands periodically or temporarily relocates to be near them for a time. These models have proved valuable alternatives to no analysis, but both impose financial and emotional hardship on analysts, their families, and patients. The analyst who offers condensed or shuttle analysis must have tremendous flexibility to be able to do so.
In condensed and shuttle analysis, periods of absence from analysis impose a strain: analysis opens to a regressive process in the patient, who then during the break must bear the disruptive effect of affects stirred up and not easily contained (Hutto 1998). Equally problematic is the tendency to shut down until the next opportunity for analysis comes around, the unconscious having a tendency to close up when the analyst is away (Fink 2007). The cycle of disruption and loss may hinder the development of intrapsychic representations, especially in patients with severe early trauma (Hutto 1998). Nevertheless, the general agreement is that condensed analysis is better than none at all (Sachs 2009). In my view, only teleanalysis at the usual frequency comes close to offering the continuity and depth of a traditional in-person analysis, and at no greater cost.
Conclusion
The analytic establishment is now confronted with the need to reconsider attitudes about analysis supported by telephone and computer technology. Some analysts believe that psychoanalysis, an art based on the harmonics of unconscious communication, cannot possibly transcend the limits of distance. But articles in the psychoanalytic literature, research, and presentations at workshops of APsaA and the IPA show that some analysts and some institutes are willing to experiment with teleanalysis as a supplementary form of psychoanalysis. Teleanalysis has been an experimental and controversial method, but there are signs that further study may lead to its acceptance. What is needed now is a federal license to practice across the United States (Linkous 2012), more complete study and review of narrative reports from teleanalyses (Benson, Rowntree, and Singer 2001), and pooling of clinical experience by psychoanalysts from the three regions of the IPA (Charles Hanly, personal communication 2009). We need to stay attuned to sociocultural changes and broaden the reach of technology, do clinical research into indications and contraindications for teleanalysis, and stay open to transformation, as occurs with every living language and culture (Aryan et al. 2009).
Psychoanalysis by telephone, VoIP, or VTC is indicated for patients without access to local help, for analysts who must be out of the office for one reason or another, and for patients with practical reasons for not coming to the office or psychological resistances to being seen in person. Fully aware of the objections to the use of technology in psychoanalytic treatment, and sensitive to the challenges it poses, and agreeing that it is possible only when licensure laws permit, I maintain that psychoanalysis on the telephone or over the internet is indicated to maintain analytic continuity and to bring psychoanalysis to underserved areas.
Footnotes
Teaching Analyst, Washington Center for Psychoanalysis; Supervising Analyst, International Institute for Psychoanalytic Training; Clinical Professor of Psychiatry, Georgetown University.