ABSTRACT

G = Galit Atlas; L = Lew Aron; H = Haim Weinberg; A = Arnon Rolnick H

Let me start with the first question, if we agree that online therapy works, and it seems that it shows similar results, how can we explain it? The body is so important. How do we explain that it works without the body?

G

I want to say that for me there is a body in an online therapy. It’s a different kind of body and it’s a different format of a body but I have to tell you, one story that comes to my mind as you say that, is that I was on a Skype session with a patient. She is in Uruguay and I’m in New York and at some point, her dog barks, and she walks away and I see her vagina. She’s completely naked underneath … so to say that the body doesn’t exist is not correct [laughing].

L

I have very little experience with online therapy or analysis. I do a lot of study groups and about a third of my study groups are online. And I love it online. I work on Zoom all the time. And my experience with my study groups is that I feel absolutely as intimate and as connected to the students on Zoom as I do when they’re in person. Sometimes, I have to say, even more. Because I feel I have everybody’s face right in front of me.

A

And how about supervision?

L

I don’t do a lot of supervision, but in general If you’re used to seeing patients who are on the couch, and you can barely see their faces at all and you see their body from only a very limited angle, shifting to working with someone on Skype or Zoom, you’re seeing more of their body that you’ve ever seen when they’re in the room. And even if they were face-to-face … like now when we’re looking at each other, I can see both of your faces with such clarity. And if you were in my office with all the distractions … here I have only your face and the top of your body, blown up. As a matter of fact, sometimes when I’m doing it with treatment, I will sit back further away from the computer, because I don’t want to be so in their face. The whole idea, that you’re not getting the body, doesn’t hold true. And I had a story just like Galit. I had this one guy who was a finance guy and he was traveling around a lot. And he tended … also he would call me to keep his hour, he would call me sometimes it would be one in the morning, or 3 or 4 in the morning for him. He would wake up to have a session. And he would call me from his bed. And he’s wearing his pajamas or his t-shirt and he’s sitting in his bed and he just woke up for the session. I’m seeing more of his body that I want to see.

G

Sometimes it feels too close and there is a worry that … some therapists are afraid that the patient sees too much of them, not only that we see our patients from too close … how much I can control it. There is also something about that fact that when you have analysis on line you can usually also see yourself.

A

Right. Do you want to say something about that, the fact that you can also see yourself?

G

I think it’s really interesting. I never thought about it, you know. Sometimes I see patients look at themselves instead of at me. I’m aware that with some patients I look at myself more than with others. There is something there to analyze and understand.

L

Yes. Since you’re talking about it I can’t stop looking at myself.

G

I know. You fix your hair, right? There is much more … we were talking and there is much more awareness, right? On how we look.

H

True, very true.

G

And I don’t want to leave out of the picture the fact that something is left out of the picture. I mean the fact that my patient could sit in front without her underwear, and I don’t even know that, right? There is a question what’s in the frame. I can sit with my phone right here and somebody can text me, and I could look at it, if I want, right? I think that’s a big question, how to keep boundaries where the other person sees only part of the picture.

L

Just in relation to that, it makes me think of the use of the phone, because for years I would have sessions on the phone before the internet and all of that. And I find that my concentration, staying with the patient, not getting distracted by the phone is much better on Skype or on Zoom than it used to be on the phone. With the phone, it was only sounds, my mind would wander and I was much more tempted to do other things or get distracted. With Zoom I feel more tuned in.

G

Right

A

But the question, maybe sometimes you want your mind to wander, you know.

H

But I don’t think that it’s the same. Do you agree, Lew? It’s not a kind of reverie, it’s a distraction.

L

Yeah.

A

I think that we might consider recommending to sit a little bit farther away. Maybe you should see a part of my body. Galit I can only see you from your chest and I want to see what is below. You see? How would it feel if I were to sit further back? [Arnon moves away from the screen].

G

But it bothers me that you went back, you know? Because now I feel too far from you. I want to ask you to come back. I feel like I can see more of your body, but I can see less of your face.

H

Galit pointed out something. The big question is whether you want to replicate exactly the conditions in the office, or not. So what would you say about lying on the couch and having the camera on the back of your head.

L

It’s a different medium and you can’t transfer it from one to the other. The idea that you look at the back of their heads just makes it absurd. It’s very different than when they’re in the room with you and they’re on the couch and you have an overall understanding and view and context for what’s happening. I think this is a really different medium and I do think it’s going to take time and experimentation to think of all of the possibilities. Jonathan Slavin, whom you may know, does a lot of internet work. And he actually taught me, because he had much more experience than I did, this idea that when I’m working with patients, to sit a little bit further back and he uses headphones and the mic so that he doesn’t have to speak into the mic on the computer, so he could be further away. And he said – and I think he’s right – that it gets you away from only a headshot, you know, where it’s nothing but the head. And people can feel like it’s just head to head, too intrusive. I don’t think there’s a right answer about which is better. I think these all become options, and just like the patient in the room may choose to sit in one chair or another or the couch or get up and switch. Similarly, with Zoom or with the new technology, some people may feel comfortable being a little back further and that becomes one more thing to study and investigate, and understand what it means for them.

H

And to discuss, maybe.

L

Yeah.

H

Because many of the differences we simply ignore. And I think that we should not ignore them but discuss them like what you did, Galit, with Arnon. If you were a therapist or a patient, maybe we should discuss it: how close do you want me? Is it ok that I’ll sit back?

G

I always try to discuss it, you know? Because the frame is different, right? I always ask the patient where are you exactly, do you want to show me around, or not? Because sometimes I’m in their bedroom. Sometimes I’m in their hotel. Sometimes other people walk into the room.

H

This is something we need to talk about, because the meaning of people walking into the room is that – and this is one of the biggest differences – that we do not control the setting.

G

Right.

H

And I wonder whether you want to relate to that, because the setting in psychoanalysis is so crucial, and suddenly we cannot create the setting that we want, because other people are walking in. what do you say about that?

L

In the times that I worked with patients this has been an issue … we’ve had talks about it. For example, if somebody’s traveling to a business conference and still they’ll take an hour out to have a session. Where are they going to find private space? Can they get a room that they’re sure is going to be private … and their concern about who else might be able to hear them. If it’s that they can go back to their hotel room and know it’s private, that’s a different situation. I think this is particularly complicated with college students. Many college students are speaking to a therapist back in their hometown, right? They started therapy before college or during high school or in the summer. Then they go off to college and they want to have a connection with the therapist. But now they’re at their dormitory, and they have a roommate. How are they going to make sure they’re going to call at a time when the roommate isn’t coming in. and then the roommate becomes a part of their therapy, because the roommate has to be consulted about when you’re going to be on Zoom. And so these are the kind of things that I think come up practically all the time.

G

We cannot go back to older ways. There is no going back, especially for the young generation, I’m talking about people in their 20s and 30s – that are doing Skype or Zoom everywhere. They do their meetings, their business meetings, online. They date online. They have sex online. Everything they do online. And that includes looking at yourself. It’s part of the frame…. You know, it becomes almost something that you don’t think about.

H

I think that it’s back to the question how much do we want to copy exactly the conditions of the office or understand that it’s a new media and we need to accept it differently and not relate to it as if it’s the same.

G

Yes

L

You know … talk again about going back, a lot of what we did was a historical accident. You know, neurologists in Freud’s day had a certain kind of office. They made their living in a certain kind of economic model. Freud said himself that the reason he set up the office the way he did, the way he charged the way he did, and the policies, he said that’s what tutors used to do, what music teachers used to do, when he was practicing in Vienna. He was doing what were the norms in Vienna in his day. And we keep doing it as if it’s a holy ritual. So things shift. I’m very much in favor of not solving these problems with rules. And even in terms of figuring out what the policies are going to be, my feeling is that it’s premature. We haven’t had enough experience with yet, and I think, as an educator, we want people to experiment, and instead of this being something that’s off to the side and they can’t talk about it during their training because it doesn’t count as kosher for the trainers, then they don’t talk about it in the training seminars and don’t talk about it with their supervisors because it’s considered something not exactly right. I would much rather encourage that while the student is in their analytic training, that they bring this material in, and the student have a chance – with the supervisor, or with their class – to compare, what does it feel like when the patient I’m working with is online, what does it feel with the patient that comes to my office. What does it feel with the patient I’m taking a walk with. And bring it into the training. Don’t keep it on the outside. If you keep it on the outside, and it’s “against the rules”, then we never really have a chance to work with it and learn from it and explore for ourselves “what does it feel like for me?”. It may turn out for some of us, that it’s not a good way to work. And for others of us it may be a very excellent way to work.

H

I have a couple of questions if I may, as a kind of devil’s advocate. So, for example, you know that in online therapy the patient cannot really destroy the analyst. What do you say about that, if we think about Winniccotian ideas?

G

Why do you think they can’t destroy the analyst? They can press a button and destroy…

H

You think it’s the same? Like wanting to catch your throat and strangle you?

G

There are ways, I absolutely think it’s the same. Not in the same form, but I think that of course they can destroy the analyst. It looks different maybe, but it’s the same. The affect is the same, the impact is the same. It’s just a different format.

H

Ok, good.

L

Even practically, they could do things to you that they couldn’t do in the office. Online, they could be googling and searching, prying for information, getting into your personal life. There are all kinds of things they can be doing that can be destructive.

H

Ok, ok. So we don’t actually need the physical contact in order to feel that we are full of destructive drives. Ok. what about the opposite?

L

We’re also presenting – and I understand you’re doing it to play devil’s advocate - but we’re also discussing it now as if it’s an all-or-nothing thing where you’re only seeing the person online rather than some kind of combination, where you’re seeing the person in-person part of the time and online … you know and certainly I think it’s worth if you’re seeing somebody online having a certain amount of contact in-person as well, so … I don’t think we have to be thinking of these in absolute alternative terms.

H

Ok, thank you. Good answer. Now I’ll continue to be devil’s advocate. A patient wants a hug from me, and online it’s impossible … does it take away something that the patient cannot get what he wants, a real hug right now?

G

Yeah … you know, yes, but they might mean something else. I mean, it depends, right? If the hug is about a boundary … I have a patient that says before he leaves the room “consider this a hug”. Which I really like. Again, it depends: is it a way to break a boundary, to get a hug? Is it a way of … fantasy of comforting the patient? Then, what are the other ways that we could find to replace this hug online. In some ways I feel that exactly like in analysis, if somebody has a need, it’ll find its way. We will see it. if not through the hug, then through something else. It’ll just have a different face.

L

I don’t think that anybody … anyone would argue that it’s exactly the same. There are going to be differences and they might be advantages or disadvantages at any given time. So I don’t think that it’s an argument that it’s an exact equivalent. The issue is can you get to the things that you need to get to more or less so it’s an effective vehicle, and some of the things may actually look pretty different and come about differently.

H

Yeah, well, I have the same conclusion. I want to go further. What about erotic transference?

G

Honestly, I cannot conclude that that’s true for everyone, everywhere. My personal experience is that erotic transference can actually become more intense, online.

H

That’s interesting.

G

Yeah … even about porn, if you think about it, right? Or about any kind of sexual exchange that is not personal, it can be objectified a little bit. And there is something I think that in-person, some people might become inhibited, sometimes. I’m thinking about it especially from comparing patients that I see both in-person and online, that I feel that there is much more erotic transference when we’re online, than when you’re face-to-face. There is something actually about what you’re saying about the absence of the body that allows that and the distance. And the fact that we cannot touch each other. Right?

H

And the fantasy works more, maybe.

G

Yeah. And I think it’s more safe, right? I mean maybe that’s even the basic thing. That it’s a little bit more safe to have erotic material come up. And nothing can happen.

H

Ok, good. Arnon, do you want to ask …

A

Yes, if we think about interpersonal neurobiology people. They emphasize that everything is going via the body and, you know, right hemisphere to right hemisphere … if we try to include this into our discussion what would we make out of it?

L

I like keeping up with what is going on – particularly, I have to say, I like reading Mark Solms. I think that a lot of the neuro psychoanalysis is used very simplistically. And there’s been a wholesale acceptance that right brain to right brain communication means that people need to be face-to-face and you need to have eye contact direct back… again, it’s unwarranted, I think, and premature. And too big a generalization. It may be that some patients need that and this may help explain why it would be useful with some patients. I don’t think that it’s a general thing, that it’s true for everyone. And I think that we have to be very careful about reaching conclusions about what’s good and what works in a general way. People talk about “the therapeutic action” of psychoanalysis, as if there’s one way of thinking about how people get better. And I always feel like there are many, many, many different therapeutic actions of psychoanalysis and it’s not that they all work for everybody. They work differently for different people. Some people get better one way and other people get better another way. And we need experimentation and diversity and multiplicity. So I’m not persuaded that the right brain … it’s not that it doesn’t have a basis, it’s being used in a very simplistic way. Peoples right brains tend to be connected to their left brains.

H

So here’s another question that is a kind of devil’s advocate. Some people think that the intimacy that is created online is not the same. And actually we cannot create the same intimacy. I know Lew that you said you feel differently. But I want to ask it as a clear question.

G

I can create intimacy anywhere.

H

Galit, I agree.

G

But I want to add something more. I’m a different person, slightly … my self-state, I would say, is different as a writer, or as a mother or as a therapist, probably online slightly. But I believe it depends on how much you are used to a format. I do a lot online, so looking at you online is not anxiety-provoking for me, it’s not unusual to me. I assume that if it was my first time online I would be more anxious. What is it that we are used to or not used to, what creates more anxiety, less anxiety – for us, as analysts.

H

This is a very good answer, because it brings a frame of reference of the relational approaches, using the idea of self-states, we have an online self-state. So do you think of other relational ideas or concepts that might help us understand or be used about online therapy? Like enactment, or co-construction, whatever?

L

I mean, just off the top of my head, I think all those concepts would apply in the same way online. People are going to enact, whether they are enacting online, they’re going to dramatize things, play things out, play out scenarios, take on characters, take on object relation scenarios, they’re going to do that online and they’re going to do that in-person. It seems to me, the idea of the medium brings up the whole idea of the analytic setting and the analytic stage, the potential space or transitional space, thinking about the nature of the medium extends what we usually think of as the frame, or the setting. It makes the frame and the setting a more dynamic one. One that is more everchanging depending on how the person is using it – how both people are using it. It seems to me there might be a potential, real advantage, in terms of training and education, if the patient were willing to have this used for educational purposes. In the same way that people use tape recordings. But, of course, this is more exposing. In the family therapy world, this has become a norm. So, it’s about the culture. And it’s about the way it’s presented to patients. I do a lot of teaching of Harold Searle’s work and he was a very strong advocate of doing live interviews and filming them. What he said was that it’s a crazy way to teach a profession, to teach a skill, that nobody ever sees anybody do, other than their own analyst. This may have potential for training that we haven’t even begun to explore.

A

The fact that recording is so simple here, you don’t have to put a camera, you just …

L

In your experience now, because it’s my experience, that the medium, the Zoom, has disappeared. I feel like we’re in a room together talking. I don’t think our conversation would’ve been any more intimate or intense or clear if we were sitting in a room together here, than it is now.

H

So very quickly the medium disappears. We feel as if we’re not mediated, until there is a technological failure.

G

But you can also say this about in-person, right? I had a renovation next door to my office, they were drilling the whole time. In my mind, in my experience, there are less and less technological failures and there are many failures in the room. I had a leak in my office a month ago, in the middle of a session. Like water came.…. In the middle of the room. There’s no technological failure that can look like that. You know?

A

I think Lew is in the best position to speak about changes in psychoanalysis, the whole question of being orthodox versus moving and playing with it.

L

Orthodox versus Reconstructionist.

A

Exactly, so I wonder if you could say something about this. How internet therapy is just another step in the change psychoanalysis is experiencing.

L

You know, Freud didn’t like talking on the phone. Even to friends and family. He would prefer to write a letter. So from the very beginning of psychoanalysis, the medium mattered. For Freud, the letter had an intimacy and directness and also a chance to revise and think about what you’re writing, that the phone didn’t have. He didn’t like the technology and that’s even before his surgery. It’s not because he couldn’t speak. He didn’t like the phone.

I think that one of the biggest issues that we have to think about: how much is psychoanalysis part of the culture, is embedded in the culture, has to fit into the culture in order to work in the culture, and how much psychoanalysis has to be removed, apart from the culture. If we completely adopt the culture, then we don’t have a place to be critical of it. On the other hand, if we’re so far removed, then we’re not relevant to the people in the culture. And it seems to me that … you know I talk about it in terms of optimal marginality. That we need to be marginal, but not so marginal that we’re irrelevant. And I think that to refuse these things, to say “oh, it’s not the same, it’s whoring down psychoanalysis, it’s not kosher”, that so removes us from where the culture is, that we’re no longer relevant. But on the other hand, to completely adopt it, uncritically, without reservation, makes us so much a part of the culture that we may lose the critical edge. So to me, the evolution of psychoanalysis is always in relation, dialectically, to being a part of the culture and yet apart from it.

H

You can replace the word “culture” with “online therapy” and it would be a wonderful bottom line I think, for our interview. Yeah, I think you phrase it wonderfully.

I thought of asking the last provocative question. It’s clear from what you say, and from what we talked about, that we need to adjust something, mostly practical things. I want to bring a radical idea. That we need to develop a new theory about online therapies, beyond the practical issue. There must be some new idea that is not exactly the same as face-to-face. What do you think about this idea? A new theory that will be more relevant and more suitable to online psychoanalysis.

L

A new theory…. I have to ask you what you mean: a new theory of what? A theory of therapeutic action? A theory of technique? A theory of mind? A theory of development? A theory of pathology?

H

More a theory of technique actually. Taking into consideration everything we talked about but somehow not just detailing “you need to do this, you need to do that” but more understanding it broader terms. For instance, intimacy. I think you are right, Galit, that you create the intimacy, and it doesn’t matter when or where. However, I do think that there might be something different about the kind of intimacy that you can create online and we need to talk about it in theory as well.

G

I absolutely agree with that. We don’t have enough data. Everything I tell you is from my personal experience. Even when I talk about intimacy I talk about my experience. I didn’t even ask my patients about their experience of intimacy. So, everything we talk about is very limited in some ways because what we need is more data, more research, more theory, more everything. And, therefore, I absolutely agree with you. We don’t know enough about it. We have to research it. We have to really understand what it means.

L

It reminds me of one story. When I started as director of ​NYU Postdoc a little more than 20 years ago, I introduced that we’ll have a listserv. And it was the first time that the program had a listserv. Twenty years ago those were just developing anew. And the analytical institutes tend to be a group of older people. So, among many of the more senior people there was a lot of resistance to the idea that we were going to start using email and listservs and we decided not to have a print newsletter. We used to mail out a newsletter where everybody got it in the mail, hardcopy. We shifted doing it through a listserv. And at first people were very, very anxious. Many of the older people didn’t want to give their emails and sign up for it, and the rationale was that it was going to make the community less personal, less intimate, it was everything was going to be done technologically. We wouldn’t see each other anymore. The fact is that that listserv became the heartbeat of the community. That is the thing that now links the whole community together. Even when something deeply personal, we have a loss, someone dies, and we immediately can reach the whole community and everyone knows, everybody can send condolences and a memorial. The internet did not have the effect of making the community less personal, it in fact had the result of making it a much more coherent community. And that was unpredictable. And I think that’s the important thing. When we’re talking about these new technologies.… Steve Mitchell used to say that the biggest secret of doing therapy is how much of it is trial and error. And I think that’s relevant here. We need trial and error. That’s the way we’re going to learn.

G

I want to add one last thing to that. It’s obvious to me that there is a lot of anxiety about online therapy. And that’s the main thing we’re dealing with. And I’m interested to hear, because you guys have much more experience than us thinking about it, I believe, that maybe the anxiety is also about losing. I was interviewed for the New York Times about two years ago about apps. Therapy apps. I think it was an Israeli company that developed a therapy app. And the whole anxiety I believe is really about the fact that technology can replace us. Not only in therapy – in everything. Today I was at a parent–teacher conference and a teacher says: soon you won’t need teachers; everything is going to be online. If there is some anxiety that not only is this a tool, but it becomes something that replaces us. And the whole idea about therapy apps, instead of therapists, you have an app that does it.

L

It’s annihilation anxiety.

G

Yeah, annihilation anxiety.

H

Yeah, I think both of you touched on important issues. I agree with you very much, Lew, that listserv can be an amazing supportive and community reach-out device, tool. I don’t know whether you know but I direct, or manage, or conduct a listserv about group psychotherapy for 22 years and it became such an amazing connecting device. The other thing that I want to say, regarding what you mentioned about the anxiety, that when the telephone was invented the newspaper wrote “that’s a disaster. People will stop meeting one another and only talk with each other on the phone. We’ll lose the connection”. It’s exactly the same anxiety.

Ok, I want to thank you very much. I really enjoyed talking to you.

A

I enjoyed it too. and I felt your presence so close to us on the screen. I think that the content is great. I think we could really use it in our book. Thank you very much.