Psychoanalysis Online: Mental Health, Teletherapy and Training

Jill Savege Scharff (Editor): Psychoanalysis Online: Mental Health, Teletherapy and Training, Karnac Books, London, 2013, 272 pp., paperback, $42.30; e-book $33.58, ISBN: 13 : 9781780491547; 10 : 1780491549

Psychoanalysis Online: Mental Health, Teletherapy and Training is a useful and intriguing book edited by Jill Scharff. This is a one of the few books available that addresses how psychoanalysis and psychoanalytic psychotherapy have begun to participate in the modern age of technology. A simple but pertinent example of this technology is that I “wrote” this review using my IPhone to create an audio file that I uploaded to the “cloud” and then downloaded to my IPad for editing.

While phones and e-mail have been a part of our analytic work for quite some time, this book focuses on the use of voice and video-calling (Skype and similar), computer-to-computer technology as a way of conducting psychoanalytic work. The different authors in this book do a splendid job of introducing the reader to a new way of conducting psychoanalysis through the Internet.

While most psychoanalytic psychotherapists have been aware of how technology has been changing our practice (these may be subtle, small, and infrequent situations but nevertheless we’re all aware of them); this type of psychoanalytic treatment is relatively new. Over the last five or 10 years, Skype and similar technologies have allowed the psychoanalytic worker to conduct ongoing regular treatments with patients, who, for variety reasons, cannot be in the office physically but are motivated to have an analytic experience. I personally have used this technology once and thought it worked well. However, I have much more experience with phone-related analytic work. Therefore, I wish the book had included more about the phone as well as the Internet. My hunch is that there are many more practitioners who have used or are using the phone to conduct analytic work than there are clinicians using the Internet. We need to be discussing those theoretical and technical issues as well.

This well-written book is divided into three sections. The first one is on technology, the person, and society. The second is on clinical issues with telephone or Internet treatment, and the third section is on the implications of Internet technology for psychoanalytic training. I found the first section to be helpful in a general manner. It was interesting but not terribly captivating. The chapters discuss the theories or conceptualizations of society’s internalization of technology.

Turning to Section Two, my interest was piqued by the many clinical examples of transference and countertransference conflicts being translated over the Internet. One of the opening chapters in this section makes the point that the identity issues and psychic conflicts described in the case material are not created by technology but intensified by it. I think this is a crucial and vital idea in that the use of Internet technology for psychoanalytic treatment is in some ways a brand-new issue but at the same time it is simply another playing field for transference and countertransference. It is another psychic arena for projection and another opportunity for us to understand our patients’ internal worlds from a different angle.

This section also presents valuable information on the ethical and legal issues of undertaking psychotherapy or psychoanalysis on the Internet. Although this is an area needing more research, this book is groundbreaking in presenting the basics as we know them today. For example, the book points out that many therapists are licensed to practice in only one state so that it is necessary to know where the patient being treated is actually located. Also, therapists need to know to whom they are talking to online because of various ethical and legal matters regarding confidentiality, underage minors, and so forth. These and other important issues are well explained in these chapters.

The third section of the book tackles the use of voice and video-calling for supervision and training and what our professional societies and international policy boards think of the new online processes. I feel that the book helps to confront an age-old problem of the institution of psychoanalysis being too rigid, judgmental, and insecure, resulting in barriers to otherwise can be beneficial to the future of the field.

I enjoyed the authors’ descriptions of seemingly small but clinically significant items that crop up in the new world of technology intersecting with the practice of psychoanalysis. These include how patients interact with their cell phones and how cell phones become part of the treatment as either as assistive to progress or as a blockage to the treatment. These types of examples in the different chapters helped me to think more clearly about many “modern” situations I encounter, such as how some patients send text messages instead of voicemails or vice versa. These types of online psychoanalytic encounters speak to the bread and butter of our profession, the transference, countertransference, projective identification process, and the many variations of defense and resistance that is now within the vehicle of modern technology. The book starts this journey of psychoanalytic understanding about how the unconscious processes are similar, yet different, when stretched through the Internet or phone.

Another example of what makes this book so helpful is that it invites therapists to examine how we conduct our practice in deeper ways: The book started me thinking about a recent text exchange with a patient and how it differed from his usual interactions. This patient is in a high-functioning depressive position; he tries to avoid conflict, feels very guilty about expressing himself, and seeks to please others by neutralizing himself. In the five-year psychoanalytic treatment in my office, he worked past many of these issues but they are still a significant aspect of his interactions, including in the transference. So, when he had to cancel a session due to a work conflict, I was struck by how he sent me a text, simply stating: “Can’t make Thursday, work meeting just announced. See you on Monday”. Compared to his usual in-person transference persona, this was very simple, direct, and even bold. Certainly, he may have been hiding behind text and found a false bravery, but this seemed more genuine. Also very interesting was my countertransference reaction. My text reply to him was “Ok”. I sent it but noticed I felt anxious and guilty that it could have been too direct, too rude, or not professional enough. We discussed it in the next session and he said he felt “a bit guilty but also refreshed” about the exchange. Text and e-mail has a way of taking out some of the interactional affect found on the phone or in person.

Most of the case examples in the book were of treatments or training that started in the office and moved online. Although I have three ongoing analytic phone treatments that are like this, I also have a twice-a-week treatment with someone I have never met in person (it is going very well), and phone consultation for two individuals I have never met in person. I would like to have learned more about these sorts of situations as well.

One of the chapters makes an interesting statement: When verbatim case notes from office psychoanalytic work and Skype psychoanalytic sessions were given to audience members of the International Psychoanalytic Association, the recipients could not tell the difference between them. On one hand, I think this shows that using the Internet for psychoanalytic work is a robust and method that widens the scope of our ability to help and understand patients. On the other hand, I think there are subtle differences that cannot be picked up in the type of research quoted in this book.

This book is one of the first to discuss the entire topic of the Internet and psychoanalytic work so it can’t very well cover everything. Free association can be even freer for some patients, however, this free association for some patients can also translate to a much stronger degree of psychic resistance and a greater reluctance to come out of the “as-if illusion” of free association and transference into the more harsh, grief-stricken reality that is slightly easier to access in the office with the analyst. I believe there may be ways some patients develop more severe degrees of transference resistance, cultivate stronger perversions in the transference, or find stronger reluctance to analyze transference when it’s over the phone or over the computer. I would like to a second volume in the future that examines in greater detail the transference and countertransference issues that arise through technology. With greater research, I think we will find some variations on what we’re used to in the office. For some patients this will only be a different degree of what they were experiencing in the office, but for others I think it will present a significant difference. Perhaps we will find we are analyzing a different aspect of their mind or that we are creating a bit of a harder working through process through a particular type of enactment. The field of psychoanalysis needs to use technology and the Internet for treatment and training, which is the point of the book and especially sections two and three.

I would highly recommend this book to all psychoanalytic therapists and psychoanalysts to find out about where society is moving, where our patients are moving, and where we need to be moving. Not all readers will agree with the book’s recommendation to embrace technology as the new extension of psychoanalytic treatment, but the book is written is a manner that will make the skeptic stop and at least consider the idea a bit more openly.

So, let’s move forward and include ourselves in this new wave. As we do so, we need to understand the exact nature of how online therapy it is the same or different from office practice so that we can use our analytic skills accordingly. This book helps to educate us about the ways that our patients are operating within the sphere of technology and how we can meet them in that new frontier. We can continue to explore their unconscious fears and desires.