Confessions of a Teletherapy Clinician

Flora E. Lazar, PhD LCSW

On any given day, when I open my email, I typically find no less than a half dozen invitations to consider how the COVID-19 pandemic has altered the fundamental features of the psychoanalytic landscape. In early April, as clinicians were urged to do the previously unthinkable—migrate to teletherapy—the mental health Cassandras launched into a bout of hand-wringing about the deprivations that this would produce in psychoanalytically-informed treatment.

In hastily-assembled town halls and discussion groups sponsored by psychoanalytic institutes and professional associations, clinicians lamented the inability to sense body language on a screen. They complained about breaking the so-called “frame” by giving patients a window into their personal spaces, a seeming violation of the principle of analytic neutrality, defining to some analysts. A few telehealth pioneers cautiously admitted that they had been engaged in phone therapy for some time, but largely, they seemed to suggest, to assure continuity of care in cases of relocation by the analyst or patient. This usage of remote technology was to be understood as a concession to analytic care, perhaps even prescience, but certainly not acceptance.

A recent dispatch, “Returning to In-Person Treatment During COVID-19—If, When, and How,” sent to members by of the American Psychoanalytic Association by its COVID-19 Advisory Task Force captured the prevailing sentiment of psychoanalytic community that teletherapy represented a pandemic placeholder and little more referring to the moment “when can we get back to normal and safely meet with our patients in our offices.” The endgame, it went largely without saying, was returning to in-person treatment.

I, myself, participated in some of these discussion groups, first with a bit of relief, but eventually with growing discomfort. As other analytically-oriented clinicians improvised COVID-safe outdoor offices on their backyard decks to provide the clinical experience they felt certain their patients needed, I settled into an unapologetic life as a teletherapist. It was a peaceful place to contemplate my seemingly-unthinkable decision to move online without advance patient notice. For many months, even as a I took the pulse of my patients about this shift, I anguished over the power dynamic that gave me the unquestioned option to abandon an important foundation of our relational work and dictate a new form for the frame seemingly regardless of what they felt their needs were.

Slowly, however, clinical life caught up. By fall, teletherapy, once reserved for traveling executives and students attending college, got normalized. It even became big business. Electronic health record providers, such as Simple Practice, began promoting their once all-but neglected integrated telehealth platforms. Suddenly, famously independent solo-practitioners were swarming to subscribe to group plans for HIPAA-compliant technology and Google souped up its HIPAA-complaint meeting platform—even rebranding it—to provide an alternative to Zoom. A form of treatment formerly relegated to the margins, often regarded with the disdain that has greeted social media treatment platforms like Better Health, was suddenly mainstream.

A number of policy developments certainly hastened this process, not least state-level executive orders permitting therapists to practice outside the states in which they were licensed, a move ostensibly justified by the dislocations resulting from the lockdown orders. Parity in insurance reimbursements for therapy sessions delivered via telehealth permitted patients to stay in treatment while therapists shuttered their offices and increased the pool of therapists offering teletherapy services.

A Paradigm Shift for Psychoanalysis

Six months into the forced migration to teletherapy, some professional groups gingerly began hinting that some of these developments might not be so bad after all. With caseloads ballooning in response to the difficulties of quarantine and school closings, psychoanalytic clinicians waded with a mixture of trepidation and some chagrin into conversations about the benefits of teletherapy for them personally and for the field. Some clinicians admitted that these changes had provided a welcome opportunity to intensify treatments with patients no longer compelled to justify the travel time to and from appointments. Others praised the relaxation—even with its attendant uncertainty—for opening access to a broader pool of clinicians. In my own practice, a number of patients asked to increase their weekly sessions, some even to the level once considered a defining feature of psychoanalysis.

Over the fall, as the wall of opposition to teletherapy began to crack, isolated conversations about the clinical benefits of teletherapy began to coalesce into more of a conversation, not about emergency adaptation, but about secular change. Will this be a paradigm shift of the type described philosopher of science Thomas Kuhn as a fundamental re-thinking of ideas? Kuhn was thinking about science and what causes paradigm shifts in science (Kuhn, 1962). Over what has now become an extended period of teletherapy, I have been wondering specifically about psychoanalysis and whether it will take a more catholic view of the “new normal” and assimilate any of the changes into the frame that we have been compelled to adopt during the past year. Or will everything we have learned turn out to be an asterisk in the history of psychoanalysis?

My feelings about the trade-offs involved in teletherapy have been informed less by my hand-wringing colleagues than by many of the patients I work with, particularly a patient who simply cannot tolerate his face and has engaged for decades in self-defeating facial excoriation. We have worked intensively for several years during which he has also been seen by a variety of medical experts and experts in body-based repetitive disorders. But it was not until he was forced to use teletherapy three times a week to share his internal life with someone staring at a screen that he was able to see a very different person than he saw himself, and we began to unlock the ruthless self-loathing focused on his face.

A Face is Worth a Thousand Words

The face has long occupied a pivotal position in the work of infant researchers, such as Beatrice Beebe and Frank Lachmann, who see in facial interactions between infant and early caregivers the underlying basis for the creation of a range of implicit experience that serve as the preverbal foundation not only of a stable and positive self, but of meaning, itself (Beebe & Lachman, 2002; Beebe, 2004, 2006). These facial interactions are thought to form the basis of relatedness and the foundation of both self and interactive regulation. Like Beebe’s famous case of Delores, with whom she conducted a decade-long analysis in which mutual gaze was critical therapeutic element, my patient located the first tendrils of health in being able to experience me and himself at such close range. This break-through would not have happened, he reported, without teletherapy.

Studying Beebe’s work on infant research and adult treatment, as well as the work of Allan Schore and the Boston Change Process Study Group on the importance of the non-verbal implicit domain, has always made me wonder why the therapeutic value of the couch has not been more consistently challenged (Stern, 1998; Schore, 2011; Kravis, 2017). Originally hailed as the sine qua non of the scientific method of psychoanalysis—a device for ensuring that patients share their free associations unaffected by sight of the analyst’s reactions—the indispensable value of the couch in psychoanalytic treatments has certainly been called into question in the last several decades. While the couch has been treated somewhat humorously, though respectfully, as an artifact of Freud’s early interest in hypnosis or more recently as a cultural artifact rather than an indispensable scientific instrument, few analysts have had the audacity of Fairbairn (Fairbairn, 1958) to question wholesale whether, “in light of the historical origin of psycho-analysis…the classic restrictions of the psycho-analytical situation are not in some measure arbitrary.” Abandoning the couch, Fairbairn warned that, “concern over the scientific aspect of a therapeutic method can be carried too far, “as a vehicle for preserving analytic neutrality,” and he went on to warn that “the human factor in the therapeutic situation…is only too liable to be sacrificed to the method, which thus comes to assume greater importance [than] the aims which it is intended to serve.”

As we edge closer to a COVID vaccine and permit some modest speculation about psychoanalysis after COVID, my mind returns to my patient, to the infant researchers, and to Thomas Kuhn, as I wonder whether some of the lessons I have learned from this patient and others through teletherapy will result in any kind of paradigm shift about the essential role of the couch in psychoanalytic treatment. Will teletherapy produce the clinical shift I felt certain it would when I first began grappling with it? Would it resemble the irony my patient pointed out to me about coming to terms with his face during the otherwise diminishing time of COVID-19? “Isn’t it strange,” he observed, “that I have finally gotten comfortable showing my face to the world at a time when I am asked to cover it up?”

References 

Beebe, B., & Lachman, F. (2002). Infant research and adult treatment: Co. Analytic Press.

Beebe, Beatrice. (2004). Faces in relation: A case study. Psychoanalytic Dialogues, 14(1), 1–51.

Beebe, Beatrice. (2006). Co-constructing mother–infant distress in face-to-face interactions: Contributions of microanalysis. Infant Observation, 9(2), 151–164.

Fairbairn, D. (1958). On the nature and aims of psycho-analytical treatment. International Journal of Psycho-Analysis, 39, 374–385.

Kravis, N. (2017). On the couch: A repressed history of the analytic couch from plato to freud. MIT Press.

Kuhn, T. (1962). The structure of scientific revolutions. University of Chicago Press.

Schore, A. N. (2011). The right brain implicit self lies at the core of psychoanalysis. Psychoanalytic Dialogues, 21(1), 75–100.

Stern, D. (1998). Non-interpretive mechanisms in psychoanalytic therapy: The’something more’than interpretation. The International Journal of Psycho-Analysis, 79(5), 903.