Interview with Julie and John Gottman 1

G = Julie and John Gottman; S = Shoshana Hellman; A = Arnon Rolnick S

So can I ask you the first question: you said you both work individually and with couples. Do you feel there is a difference using Skype with individuals and couples?

G

Yes, there is. Significant differences. First of all, with individuals, the individual is relating to you, so it’s one-to-one. Though technologically it’s a little bit complicated in that eye contact is not as easily made, given what computer people have, and sometimes the technology is not perfect: it will freeze, or it will do some funny stuff. And so we have to adjust to the whims of the technology. But in couples’ work, I think it’s much harder. And here’s why: first of all, in order to see both people, they have to be sitting very close together, which is usually an unnatural positioning for them. And they’re both looking at me, when many times what I want them to be doing is to be speaking with one another, they may look down or somewhere else, as they’re talking.

The other thing that makes it difficult is body language. I can’t read their body language well. And I think there’s also something very significant about sensing.… Trying to sense what’s going on between them. And it’s much easier to do that when you have the actual, physical energy of the people in the room you’re in, rather than on a screen that is a tiny bit fuzzy. And for some reason there’s some kind of phantom in the computer so that when they’re about to say something incredibly important, the screen freezes. The phantom knows when that’s going to occur.… So what can you do, right? You have to wait. It’s kind of like watching a really good mystery show, where you’re in suspense and you don’t know what they’re going to say and you’re dying to hear what they’re going to say, it’s frozen, and then it finally comes through. So you have to adjust all this. I don’t think it’s as efficient or as effective of course as working face-to-face.

S

And in terms of individual therapy would it be more efficient than couple?

G

Yes. So working with an individual, I mean they’re looking at you as much as they can. You don’t have to look at anybody else. So I’m connecting with them. But at the same time I don’t know what to call it, but there’s something that’s very intense about face-to-face connection, body to body in the same room, where you’re, you know, for lack of a better words, you’re picking up energy about what’s happening in the other person. And that energy for me is often very telling. I have much more intuitive sensibility when I’m working with somebody face-to-face as opposed to on the screen. But with that said, you see, the fact that I can continue a form of therapy at all from thousands of miles away – I mean I have done many Skype sessions for example with couples in Australia, and for me that’s a very long distance, you know it’s 10,000 miles or something. So the fact that that’s even possible is really miraculous, and I’m looking forward to the steady improvement of the technology over time.

A

Do you think you must begin such therapy face-to-face and only then move to Skype sessions?

G

I will only begin in Skype sessions with individuals. That, I’ve done. For example, I have an individual that started with me and she lives on the east coast. So that’s about 3000 miles away. And I’m seeing her regularly. But with couples, it’s a different story. I think that first of all, in our couples’ therapy … as you know, we do assessment. And that assessment piece is super important. It really guides everything that we do subsequently … and I also need to build a lot of trust, a lot of relationship with each person in the couple. And it’s very important for me to see how do they relate to each other under normal circumstances. When you have even further alterations from the normal way that people would relate to each other, in a room, you’re moving even further away from some of the difficulties they encounter in their relationship that you want to treat. And so I don’t feel I get a fair enough assessment, from beginning just over technology.

S

So this actually relates to the next question, which is obviously, you have very specific principles to your approach. I know that for example, expressions are very important, the assessment is extremely important, and physiology. So how can you really integrate all these principles of your theory and still use couples’ therapy on line. Can you do that when you use Skype?

G

You certainly can’t if you begin with Skype. That’s why I do not. I only do Skype after between 15 and 18 hours of intensive therapy. In the intensive therapy – a marathon therapy – I meet the couple for three consecutive days, five to six hours a day. So I get to know them quite well, in that time, and after that I’m willing to do Skype, when they’ve already made some progress. But for some people, depending on what the issues are, I’m probably not going to do much Skype, they may have to come back. For example, we treated one couple, where the gentleman was a famous person, he travelled a lot, and he had had 57 affairs in 12 years. And three of them he had fallen in love with, he had three young kids at home. And so, we got pretty far in our first marathon, but definitely they needed more, face-to-face intensive especially when you’re dealing with that much intense emotions. And I’m not talking necessarily about the way that somebody might be a very passionate person or a very intense person and how they verbalize their emotions. I’m talking about the pain that is so profound, that has been caused by the other person, that the kind of support that they need and that the other person needs also, to almost be held psychologically as they’re hearing the pain of their partner, and not wanting to jump off a bridge, is something that I don’t feel comfortable doing over a screen. I really want to be there in-person to do that work. I guess also, that would be the same for people with severe PTSD. So, for example, I’ve done some work with couples with very severe PTSD, including combat. One fellow for example, who was in the Marines here and during the Iraq and Afghanistan conflict he had had 13 deployments in about 14 years. So he was barely home and he was doing very secretive, deadly, mission work. And … a young guy, he’d gone into the Marines at 18, he was now 32, and he had so much trauma he could barely see straight. And meanwhile he’d also had an affair too, abroad, which is a common problem among service people here, especially service men. And that, too, is the kind of treatment where I wouldn’t feel comfortable just doing it over Skype. There’s just too much agony between them and especially inside him. So when you have really severe symptoms like that, for this guy, I mean, it was terrible, very severe. Then, it’s risky to do it. Especially I think in America we have a very different problem than you guys have, in Israel, in which we have almost as many suicides in the armed forces, as we have people being killed during service. The suicide rate is incredible. Because they don’t get help. And so these people who are walking around, walking wounded, are just in a terrible state and high risk. That’s not the kind of thing you want to treat over Skype.

S

And was this case also like a long-distance relationship? I mean did he have a relationship too?

G

Yes, this was a couples’ case. He had a wife and two children at home. The wife had an affair too. And he did not talk about any of his combat experience before the treatment with his wife. Not so much because he was afraid she couldn’t bear it, though that was definitely a part of it, or that she might hate him, but because he couldn’t bear to think about it himself and he was already so consumed by the memories of it. At night, especially, when there was no distraction. He just couldn’t bear to go down deep into it. Except that finally, he did.

S

Which brings me to ask about couples who have long-distance relationships. I wonder whether you see some of those couples and whether those are treated via Skype, because obviously that’s how their relationship goes. So did you see any of those?

G

We’ve seen a lot of couples with long-distance relationships. But those couples come together for therapy, so they are not doing what you and Arnon and I are doing [each one of the interviewers and the interviewee were in different physical spaces] right now, where we have three different screens. They’ll come together for a weekend, every couple of months or something, and during that time there’ll be some treatment. Or they’ll come here for an intensive. So yes, we have seen those couples, and the long distance certainly creates strain. It’s a very difficult process to have intimate relationship.

A

Since what you do is not only to do the therapy but also to give suggestions to a couple how to make their marriage better, have you ever written or thought to write how to do long-distance relationship with Skype or a method like this?

G

That’s a good question, Arnon. We have not, and the reason we have not is because we don’t write anything unless we’ve done research on it. And, you know, though there have been a few long-distance couples, here and there, we haven’t made a conscientious study of their relationships. Other people have, but we haven’t. And we haven’t tested out treatments with couples like that and we definitely haven’t tested treatment over Skype. So it’s not something we would write about unless we’ve actually conducted research.

S

Let’s move from couples and long-distance relationships to family therapy. Is there any type of family therapy that you have done actually? I know that you’re not doing too much family, you’re doing mostly couples. Maybe just what is your opinion about family therapy. Do you think it’s possible to do it via Skype?

G

I don’t know. I don’t do family therapy except with adult people. I’ve definitely done family therapy for parents and children when the children are grown and adults. And I guess the more people I think you have on a little screen, the less information you’re getting for every individual. Because they’re further away from you, they’re more blurry, you can’t see their faces unless you have multiple cameras operating, and you don’t, usually. So I think you’re losing a vast amount of information as opposed to doing it more closely. With younger children, depending on what you’re talking about, kids would want to get up and move, they’re not gonna want just sit in one place. That’s hard. You can’t do that either over a screen. With teenagers, it’s possible but again, you’ll be losing a lot of information. I think really the most you can comfortably have on the screen is two to three people. Two of them on one screen and the therapist on the other. Three? I don’t know. I think it would be pretty hard.

A

I thought that one of the reasons it was important to interview you was that you do emphasize the role of the physiology and the role of the body. I was somewhat happy to see that you published a book in the interpersonal neurobiology series.

G

That’s right. That was my book.

A

So if you take it into consideration that we need to “hear” the body or to sense the body or to sense the central nervous system, and I know John did a lot of work about physiology, like measuring the heart rate. I wonder where is this direction when we conduct Skype sessions. And if we do speak about Skype therapy, what do you think if I could see your heart rate now on the screen. Would that help in any way?

G

Yes, I am in favor of heart rate monitoring. A heart rate of greater than 100 beats a minute appears to be the cutoff at which most healthy hearts begin being affected by circulating adrenaline and cortisol, activating beta sympathetic nerves that increase cardiac contractility and rate, constrict arteries, and contribute to the physiological cascade of events that accompanies fight or flight and has huge consequences for cognition and affect, usually without the person’s (client’s and therapist’s) awareness. What seems like “resistance” may be the consequences of diffuse physiological arousal.

A

Initially you suggested measuring heart rate to evaluate the level of arousal of your couple. These days there are more advanced methods to measure not only heart rate but also Heart Rate Variability. Would you consider adding such additional measures to face-to-face and online couple therapy?

G

Heart rate variability is an okay substitute for RSA (respiratory sinus arrhythmia), which can be assessed quite effectively from a spectral analysis of the area under the spectral density function of the heart period time series within the usual adult respiratory range. That computation is a better measure of vagal tone, which is what we want to sharpen in our clients (and the therapist).

G

Sure. Yes, of course, it would help. We are actually working on some technology to create therapy and track therapy including physiology over screens and it’s a work in progress. Physiology plays a very important role. Heart rate of course is important, sometimes you can tell some things by respiration. And you can watch respiration through subtle movements, flesh tones for example will subtly change color with breath. Also there are tons of devices out there for heart rate, you know little pulse oximeter that can be joined through programming into different technological screens and integrated into what you’re doing. So yes, that is an important thing. Sometimes I have had people on Skype, I had them purchase for 19 dollars a pulse oximeter to wear on their fingers at times, I’ll ask them to do a conflict conversation. It’s for themselves, what’s happening, and the ones that we get have alarms built in so if their heart rate goes above a set number, usually 100bpm, that’s a sign of diffuse physiological arousal, and I can hear the alarm going off and so can they, of course. So I know that they’re getting flooded, and then we’ll do something around that. So, there’s also technology made by a company called Heartmath that I’ll ask people to work with just to see whether or not that strengthens their ability to resist flooding. So, yeah, the short answer is physiology is very helpful, very important in terms of integrating that into the therapy.

S

You are doing it on Skype, from what I heard you say. So because of the alarm, because of the facilities of using it even online, you can use it actually, using Skype and doing your intervention.

G

Right. As a matter of fact there are probably ways of doing things, but you’ve got to have multiple cameras, that’s really the secret. I was thinking about our research lab, which we just opened up again, and we’ve got three cameras, we’ve got split screen, we’ve got program integrating both physiology monitors and so on, into what’s happening with the couple as they talk to each other. All of that is getting registered on one screen, but our focus has not been to do therapy via a screen. Our focus is doing the therapy in-person and analyzing all the data that we collect. I suppose theoretically you could set up something in a very complicated way, but the problem is the couple would have to be in a place where you’ve got all the equipment.… And you are somewhere else.

A

Suppose now I’m with you Julie in the same room, and you could see that I’m excited. That’s one thing. And now I’ll describe another situation when we are not in the same room, but you see [via some sensors] that my heart rate goes up. Theoretically, it’s the same experience that you see that I’m aroused, but my feeling is that it will be a different type of right hemisphere communication. When I see you now, and I see in your face that you’re trying to understand me, this information is coming from the right brain, I think. If it was with the sensors, I think you’ll say “ok, Arnon’s heart rate is going up, or Julie’s alpha wave is going down” – it’s a different type of analysis. Do you see where I’m headed to?

G

Sure. I totally do. I think, Arnon, you’re making a good point, and it is what I was trying to say before, actually – not very articulately, maybe – in which when I’m sitting in the same room with you, I can sense you. As opposed to seeing an oscilloscope, say, with little waves going up and down. It creates a very different response in me. And that response guides how I intervene. So if I’m seeing signs on a screen, let’s say, that your physiology is going up, I’ll have a very cerebral reaction to it. If … left and right brain stuff is not quite what it seems, so I don’t tend to use that kind of language, but it’s certainly a more removed response. It’s an intellectualized response. Whereas when I’m in a room with you, I’m feeling it at a much deeper level. And therefore my intervention tends to be probably more powerful and more effective when I’m face-to-face with you. That’s because it’s coming not only from my intellect in analyzing what’s going on to cause what you’re feeling, but also what I’m sensing, what I’m intuiting. Just being in your presence. So, you know, can doing therapy over a screen really duplicates that? Not that I’ve seen.

S

There is an article of a psychoanalyst that talks about distance therapy and whether empathy can be shown on screen and can be felt as real. I want your answer because you integrate emotionally focused therapy in your approach and then you mentioned extreme cases of PTSD but what about other cases of emotions?

G

Well again, you certainly can’t transmit empathy visually as well. I think in terms of the words you use, how you speak, the sound quality is much better than visual quality, as it is registered by the listener, by the receiver.

A

I’m not sure I understood.

G

What I was saying is that sound quality is transmitted much more clearly than visual quality to the receiver, in Skype.

S

So you mean to say that in Skype the sound is more important than the visual, or it’s more effective?

G

No, what I’m saying is that when you compare the sound and visual of Skype, sound is certainly more finely tuned, it’s more effective, than visual and here’s where it comes into your question, Shoshana, which is I think you can convey some empathy through your voice, through the words of course and also through the tone, through the pacing of it, the volume of it.

G

So again to your point, I think you can express empathy. you can do a better job expressing empathy through voice, but on the screen you really lose the eye contact, the facial nuances, that convey empathy, the body movement that conveys empathy, you can’t do it on a screen. So you probably lose 50% of the power of the empathy you’re trying to express to the other person. And you do the best you can.

A

Speaking about empathy. Can we use facial expressions? I believe that John was one of the first researchers to use the Specific Affect Coding System (SPAFF), to code participants’ behavior for specific affect from video recordings.

G

I not only used the Specific Affect Coding System (SPAFF), I invented it. So yes, it is a very effective coding system, and in the couples’ arena better than Ekman’s Facial Affect Coding System (FACS) in predicting longitudinal outcomes (that result is published). But FACS is fabulous. Paul Ekman has made an enormous contribution to our understanding of emotion.

A

In online therapy the camera is already there, and the picture goes directly to the computer. This can therefore be a great opportunity to show the patients their facial expressions as translated by the computer to “emotional scores.” You are probably familiar with MIT/Affectiva solution which can use a simple laptop camera to assess human emotion. Would you consider adding such a non-intrusive method for couple therapy in general and online individual or couple therapy sessions?

G

I am familiar with MIT’s media lab work, and automated facial coding in general. So far it’s not good enough, unless misses are not counted as unreliability. Still we have to show that a particular automated facial affect matches observers by 90% or more. If anger is coded, it must be coded anger by both automated coding and observers. A serious problem is the corpus of photos used is mostly garbage. People are paid to display an emotion and that photo is accepted without questioning it. So, for example, the corpus of disgust expressions are people sticking their tongues out, instead of upper-lip raises or nose wrinkles, classic disgust expressions. Also, posed and spontaneous expressions are very different. So a lot of automated coding with a bad corpus of photos is garbage.

But, yes, I am in favor of automated coding. It would add so much. So many therapists are actually not competent in detecting emotions. I know that’s a damning conclusion about therapists, but, where do they get trained? Not in graduate schools. That’s sad, but it’s more likely that they will get trained in projective testing than in learning how to read micro-expressions on the face.

A

Here is a broader question: Research shows that the result of Skype or online therapy is as good as face-to-face therapy and even that the therapeutic alliance is also as good. How would you explain that?

G

First of all, I want to see the research and see the measurements and how they’re assessing what they’re actually assessing. For example, therapeutic effectiveness, what level of therapists are they using. So you can have mediocre therapy being equal to mediocre Skype work, and so therefore they’re equal. But that doesn’t mean it’s good therapy. So you got to look at the research more carefully. You’ve got to analyze what they’re actually looking at, and how they’re measuring it, that’s very important. And, you know, typically. … A lot of the studies will use self-report as a measurement and self-report is a terrible measurement. And there’s a lot of research on that. Especially in therapy where you know the client is trying to be pleasing to the therapist, because they’re grateful for whatever the therapist is giving them. And if it’s part of a research study, it’s typically for free. … So you got to really look at the research, Arnon, and not necessarily take it at face value. So, the other thing I would want to see, is in terms of effectiveness, I would want to see a longitudinal follow-up. So maybe right after therapy ends they’re feeling better. A year later, are they still feeling better? You know. I want to see that. So you’ve got to have a pretty high bar when it comes to evaluating the quality of the therapy.

A

Another question which is still related to what we spoke earlier, you are of course familiar that in some cases … there is an erotic transference either in individual therapy but also could be between the therapist and one of the partners of the couple. I wonder if you think that erotic transference would happen also in Skype therapy.

G

That’s hilarious. It depends on how big the screen is and whether the client is seeing the entire body of the therapist or just the face. And I’m saying that a bit facetiously. I suppose … of course it could still happen. Because it is in fact transference. It’s a transference. But it’s probably not quite as likely to happen because of a variety of things. I don’t know. I don’t think anybody has ever measured this; it would be an interesting study, to look at pheromones of clients in therapy which in fact is largely responsible for being physically attracted to somebody. So obviously those don’t transfer through Skype. Yet. Maybe it’s coming. And when you’re looking at just a not very well focused face you still get erotic transference from just the therapy itself really, and very little about the physical presence of the other person. I don’t know. You know, it would be an interesting study. I’m sure it’s possible, and I’m sure it happens, but I don’t think it happens with as much frequency.

S

There’s one more question that is not related at all to this. Do you know about the interventions that are online, a lot of self-help interventions online, Many therapists are using them. I know that you are using of course the assessments online. But there are also video ones. Is there a way to integrate those? Are you thinking how are those computerized interventions integrated. Obviously, I don’t think it is in your approach but what do you think of these kinds of self-help video computerized interventions?

G

We’re actually working on that as we speak.

A

In what way?

G

I can’t go into a lot of details, but what I can say is that I do think it’s possible for interventions, especially dyadic interventions to be conducted through technology. So anything that goes deep, relies on the therapist’s judgement, intuition, orientation and so on, is going to be much harder. You’re not going to be able to do that. But, when there are interventions that are very simple things, then I think you can give people instruction on how to do those things with one another and have them do them, hopefully successfully.

S

So you can integrate them also in your sessions, in your Skype sessions, let’s say?

G

Well … we do that in our Skype sessions. We are doing that in our sessions.

A

I wonder if you are doing a group supervision via Skype.

G

Yes, we’re doing tons and tons of group supervision via Skype. In fact, most of it. We have certified master-trainers who are part of our certification training. And they do group Skype meetings with small groups for consultation to direct people to get certified. So we’re doing a lot of that. All over the world. It’s the only way that we can actually train people through to certification, when we don’t have a certified trainer in the country itself, or even, you know, in the city. So yes, most of our advanced training, in fact, is done that way. The final process. Stage 4, I guess you call it, of our training. Ok, so the first question, the future.

A

We would like your opinion about how technology affects human relationship.

G

How does technology affect relationships? The jury is still out on that. Potentially, it can create greater community. Also, it may be used to hurt people, separate people, have people rely on text instead of face-to-face interactions. It can be quite harmful. But people also said that about the telephone, and it was an unfounded worry. So I don’t judge it as harmful. Like other aspects of technology, it can be used to connect people, or it can be used to distance people. I found it delightful to think about David Levy’s book Sex and Love with Robots, because he asked the question what does it take for a human to fall in love with a machine, and the answer is not much. Some people on the planet will choose blow-up sex dolls over making love to a real person, so why not make them available to those people? Maybe it will end prostitution and sexual slavery. I think it is foolish to condemn technology without thoughtfulness. For example, in creating a virtual therapist the program Eliza (and its new incarnation woebot) a randomzied clinical trial showed it to be effective with depression. How many therapists can claim that? So Eliza may increase the competence of therapists in the long run.

G

So, what’s the future? I don’t think the human being will ever be replaced. I think what is the most effective is face-to-face work. I mean that’s just my own prejudice. No matter how good computers get, no matter how good robots get, or robotic programming, and so on. Even with Artificial Intelligence. Everything is going towards machine learning and artificial intelligence, which I think is fabulous – I mean it’s really pretty incredible. And … that’s part of our work as well, some of the stuff we’re integrating.

A

You give us an interesting message. On one hand I understand that you are working with some Artificial Intelligence and robotic-like interventions and at the same time you say that we still need the human touch.

G

That’s right, in a nutshell.

A

Have you tried new devices like Alexa for such work?

G

In terms of therapy, my fundamental philosophy about therapy is that – and this is going to sound really cheesy or corny or very American or something. Or optimistic. But I really do believe that the therapist’s love for the client is what heals the client, ultimately. And how do you transmit love over a screen, especially building trust in the first place. Before really knowing the client well. It takes a while and I don’t know if it can be done.… I don’t think it can be done as effectively on a screen. I think you need real contact. I think there’s something about how nature was created that is perfection on every level. And that what is natural is being-to-being contact, being-to-being communication whether it’s animal-to-animal, or person-to-person. And we are animals, ultimately. So when you put a chunk of [meat] or other material between you and another human being, then what? Well, it’s dehumanizing to some degree, and we’re trying very very hard to negate the results of that dehumanization of connection but again I’m such a believer that what is natural is right, or best, in some ways, that it will never duplicate what is possible in person-to-person, face-to-face. So I think we are always going to need that and we need that perhaps more in the more severe cases but everybody needs it anyway. So we can move towards greater and greater mimicry of human connection and artificial intelligence is all designed … you know, all hoping for that, in fact, when machines learn the way humans do. But is that going to really create real feelings? Well, sort of. But ultimately, human-to-human is best. In terms of couples’ therapy, same thing.

A

I think that would have been a very nice way to summarize the meeting. I never met you, you never met me, and yet, our communication was as synchronized as your communication with Shoshana.

G

That’s true. But, we are talking on a cerebral level, Arnon, We’re not talking about deep feelings and emotions and pain and traumatic history, and … childhood. Right? So yeah, sure, at this level you could do a lot, intellectually you could do a lot. But that’s not where real healing takes place. I’m not trying to heal you, and you’re not trying to heal me. We’re having an intellectual conversation. And yeah, sure, you could do that.

G

I think to your point Arnon, there’s so much need out there, there’s huge need for so many people, to get help and especially for couples to get help, in every country that there’s no way in the world there could be enough therapists face-to-face to supply the help, if … 1% of those people even want to avail themselves to that help. So I think technology serves an incredibly important purpose in being able to reach many, many more people with at least a modicum of help, some amount of help. It’s not going to be perhaps the same quality, but let’s not go with “all or nothing”. Let’s go with what is possible. What can we give. And any help is better than … if it’s the quality, and the research backs it up, in how effective the methods are, let’s give whatever we can out there, to reach as many as we can. Good enough therapy. Good enough marriage. It doesn’t have to be perfect.

A

Toda Raba [thanks a lot, in Hebrew].

S

We really thank you so much for your time, we really appreciate it.

G

It was fun, it was wonderful. Thank you for reaching out to us, thank you.