Remote Therapy

Let’s try to describe how a remote (skype, zoom, whatever) session differs from a regular session.

 

  • You see much less body language
  • The normal on and off of face to face contact and eye contact is mostly on
  • You see the face more intensively and close up
  • Your face is visible more intensively and continuously
  • There may be an option of nonintrusive saving – by therapist and client

 

How do these changes affect the experience of the client and the way the therapist uses herself?

 

From the outset the intensive intimacy of the therapeutic experience required some regulation. Freud began by pressing on foreheads to release repressed thoughts, or using hypnosis. Only with the introduction of “psychoanalytic technique” was the physical relationship in the room set in order. This order was designed to allow maximum freedom for both analysand and analyst. The client was free from normal social contact, rested on a couch and was encouraged to say whatever entered her mind without any censoring. Many of these “free associations” would have been inhibited in that cultural context (Vienna, c. 1900) by face to face encounter. In addition, Freud once said (or quipped? – with Freud it was sometimes hard to tell) that he needed to sit behind the couch because he could not tolerate having his face stared at 10 hours a day. We could translate this to mean that when the therapist’s face is seen by the client, the nuances of the therapist’s reactions were too readily exposed and may well inhibit the freedom of client and therapist.

 

As you recall from the lesson on Buber and the Brain, since 1997 we have come to understand that by way of “mirror neurons” we affect each other directly and instantly, before there is time to “think” – i.e. before there is time for re-entry between thinking (prefrontal cortex) emotion (limbic especially amygdala) and body (midbrain). This involves our feeling that the muscles we see in action in a complex meaningful action in the other is experienced immediately as if it is our own action. Recall the baby “imitating” sticking out her tongue, which turns out not to be imitation but rather her experience that is her tongue that is out before she sticks it out. Probably emotions which are generally directly expressed in stereotypic movements of facial muscles work in the same way. So a smile does not exactly draw out a smile – rather you feel my smile as if it is your own. This comes down to the fact that intensive face to face contact does indeed create direct effects on the two conversants. Freud was right that this would have a negative effect on freedom.

 

But then, the therapy we do today is less about freedom to express what is already there and more about the evolving mutual relationship between client and therapist. We more readily accept the fact of mutual influences and try to use them to understand relationships. Face to face contact, especially incorporating mirror neuron understanding, would lead us to make use of the continuous dance of emotions that takes place in the room. What we lose in freedom we gain in participation. The intensive direct expression of emotion brings us into close contact with our clients.

 

The closer intimacy (the paradox of being far and feeling near) will be a blessing for some therapies and therapists and a burden or challenge for others. There is no single answer here. Let’s try to sort this out:

 

First of all, a therapist has to feel comfortable and secure in the modality she employs. There is no one “right” modality, each has advantages and disadvantages. Can you, as a trainee, feel secure with the intense face to face communication? It may be premature for you. If it makes you feel less free, then don’t use it. Use the phone. With no apologies. You need to be in a secure place.

 

Is this modality good for your client? Here again there is no “right” answer. I think that with clients for whom ”regulation” is primary, you may find that the loss of freedom creates an eerie sense of a struggle over whose face is plastering itself on whose face. If you have had the feeling with a client that there are many necessary breaks in eye contact during a session, then the face to face video may be too much for the client. Use the phone.

 

On the other hand, there may be clients – I suspect where the intersubjective is primary – where the video may create an enhanced sense of mutual meaning-making, something that would perhaps be too intimate if it took place in physical presence. You may have a sense of more freedom to enter into co-creation which you may feel the I-Thou more fully. If both you and the client feel secure in this area, give it a try.

 

What about saving the session?

Family therapists were among the first to make use of video feedback. One of my teachers in 1979 was Ian Alger, who was busy with reel-to-reel taping of couples. He would stop a session and let the couple see how they looked. It was very instructive, sometimes transformative. From the late 1980’s I would regularly tape couples sessions. These were the days of VHS cassettes. Many couples would ask to take the cassette home and review it. There were times when this had a transformative effect.

 

What about the client taping an individual session?

I don’t have direct experience, this is something that is only recently convenient. You would need to feel pretty confident, and if you are not, then demur saying it adds an extra burden to your concentrating on the session. But if you do experiment with it, let us know what you learn.