Some considerations on online psychotherapies

In the aftermath of the covid-19 pandemic, there has been a remarkable spread of online psychotherapy. All colleagues have grappled with this modality in an emergency phase and now, what we are witnessing, is a spread of remote psychotherapy as a means that is no longer an emergency, but routine practice.

I would therefore like to propose some reflections based on my clinical experience, on observations I have had the opportunity to make in the course of my practice and that of some colleagues, and which I have gathered from patients themselves. I will therefore also try to frame these observations within my theory of working technique.

The differences between in-person and remote therapy

The differences between face-to-face and remote encounters can be listed in two points:

• the environment in which one meets
• the sensoriality

1. The frame

In presence, the clinician receives in his or her environment, arranged and designed to favour as much as possible the analytic process. The clinician is responsible for the therapeutic frame, its confidentiality, isolation and protection from outside intrusion.

The physical environment is a metaphor for the therapeutic listening: it is a place where one comes to bring personal contents, which one thinks about projectively between sessions, where the analyst works, reflects, and studies.

Conversely, in virtual therapy, the patient becomes partially responsible for maintaining the frame. The patient may decide to make the video call at home, in one room rather than another, but is not always able to limit the intrusions of the usual living environment.

On this, I can testify to a variety of situations, from the most innocuous to the most serious. On one occasion, in the middle of a session, the connection broke down and when I reactivated the call I was confronted by a gentleman I had never seen before, who could not explain to me what he was doing there. I then reconstructed that the patient was using a company account for calls and, when I called back, I was answered by one of their colleagues.

In other cases, the patient's son enters the 'therapy room' to come and see what their mum/dad is doing. Some other times the patient, in the absence of a suitable and private environment, logs on from the car.

These are always situations that can be avoided, corrected, improved or prevented, but the point is that we are, in fact, asking the patient to take responsibility for holding this listening and receiving space.

Colleagues who habitually and exclusively use remote therapies usually charge a lower fee, as if to compensate for this shared responsibility in maintaining the meeting environment. In my opinion, the financial aspect, rather than resolving the issue, signals it more clearly: it underlines that online is worth less. However, in some respects there is no scale of values: either things are done well or they don't work, they become something else.

Another aspect is that with remote sessions we allow the patient to let us into a part of their real life, to see parts of their home, the furniture, the pictures, and the rooms where they usually live. It is true that virtual backgrounds can be set up. I must note that I have never had a patient use this setting. Also, the use of a virtual background only circumvents the issue: even the choice of the background communicates something about the patient. 

It is true that this, like anything, can be used in therapy, but it is also true that this becomes a coercive and intrusive aspect of communication. Moreover, and this I believe is more important because it always relates to the therapist's sense of taking responsibility, the patient is hardly ever aware of the sense of intrusion that remote connection into his or her intimate space implies. 

It is a situation analogous to the limitations usually given to the therapist-patient relationship: there are no meetings outside of the sessions and there is no provision for the therapist to have professional or non-professional contact with other acquaintances of the patient. 

This set of precautions is made explicit and respected by the therapist; often the patient does not understand them immediately, but only later, and then eventually appreciates it when something happens that ends up highlighting their importance (e.g. when the therapist and patient meet by chance outside the office). The use of remote sessions proposes a similar situation in my view. The fact that the patient is not disturbed by the remote sessions may simply mean that he is not aware of the impact that these changes in setting have on them.

So I would say that there is a kind of inverted voyeurism, exhibitionism of the intimate, forced intrusion by the therapist. The listening space in the session is a place of suspension and encounter at the same time. The patient enters into another place, separate from every aspect of his or her daily life, where he or she suspends the flow of his or her life in order to allow the emergence of any sensations that, due to aspects of his or her personal psychology, have been dispersed in some way. At the same time, the flow of these sensations-perceptions meets - in the therapist's listening space - with thoughts, images and projections.
 
The listening space in therapy is a space of suspension and encounter between minds, and this makes possible a shared dreaming, a reactivation of mental processes. It is a virtual, artificial space in which fantasy becomes real and vice versa. When a remote device is used for the listening space, virtuality becomes inherent in the technological medium. The image of grafting robotic or cybernetic parts onto human bodies comes to mind. We no longer imagine being artificial, but parts of us become truly artificial: the virtual makes fiction real, and deprives us of our imaginative possibilities.

The electronic medium connects me to the patient's bedroom: I see them, I see how they keep their bed, the pictures on the wall. As we know, sight is the worst enemy of imagination.

2. Sensory

Remote encounters are based on a profound 'perversion' of sensory aspects. In addition to not breathing the same air as our interlocutor (a requirement raised to sacred status in times of pandemic), there are many other sensory aspects that are perverted. 

I speak of perversion because the sensoriality of the face-to-face encounter is not simply subtracted or suppressed, but rather deviated in ways that in some cases mimic the real thing and in others amplify some aspects to the detriment of others.

The most deviant aspect of all, of which I am grateful to a patient for pointing out to me, is that relating to sight. In a remote meeting, we never know if we are really looking into each other's eyes. If I look into my interlocutor's eyes, he will not feel that he is looking into my eyes; to achieve this effect I would have to look at the camera and not at the image of his eyes.

The asynchronous aspect of gazing is by no means trivial. We know well how the first awareness of self is based on the reflection of the mother's gaze.

Another aspect inherent to vision iswhat I can see and what I cannot see. Both participants decide on the cut to give to their frame.  We talk with our whole body, we listen with our gaze and with our gaze we communicate, while listening we may feel the need to look at the person's face, at a part of their body, look at a part of our body or not look at all. It is not a conscious process, but it becomes part of a stream of communication between the unconscious of the participants.
The patient's emotion shines through his/her whole body and vice versa the emotion of the listening therapist and to some extent, the containment of that same emotion shines through the therapist's body.

All this we cannot see through a screen, except in a partial way. This partiality is sometimes sufficient, but for it to work it must be based on the memory of a perceived totality: only if the patient and therapist have already seen each other habitually in presence, the remote encounter becomes a sufficiently valid substitute in this respect.

Finally, as far as vision is concerned, and this I think is the aspect that the remote encounter adds unduly, there is the possibility of seeing oneself in interaction with the other. What therapist would think of placing a mirror behind the patient and one behind the clinician in their therapy room? Who would design a therapy room so that both participants can constantly see each other while interacting? Who knows if this could not be understood as an unconscious compensation for what the asynchronous gaze cannot provide: since I cannot mirror myself in my interlocutor's gaze, I see myself while talking and listening. Remotely I do not have a therapy session, but I see myself having one: as if this could reinforce the sense of unreality inherent in the remote encounter. 

The other senses are reduced (hearing) or amputated altogether (smell). On this I merely observe that we deprive ourselves of the shared perception of an environment. It may seem trivial, but it is important to bear in mind that the simultaneously shared perception of a sound or smell makes the encounter three-dimensional.

At that moment, the two participants in the encounter share the perception of a third object. This eventuality in my opinion amplifies the possibility that the encounter between minds becomes tout court three-dimensional, that there is the possibility of perceiving each other as observers of third and shared objects, as well as observers by extension of the patient's mental processes as a third and shared element.

The last point I would like to examine is the fact that erotic and aggressive feelings and drives take on a very different importance. This of course does not imply considerations in absolute terms, but is always relative to the specific personality structure of the patient, as well as to the particular moment of his or her therapeutic journey.

We present some simple considerations from the patient's point of view. The patient speaks, is on the couch or sitting in front of us. They begin to feel threatened, and guilty, for some reason. They attribute to us - who are listening to them- a feeling of anger and disapproval. I do not believe that the same possibility could be experienced remotely. I am herein not speaking of intensity, but possibility. 

I believe that the remote simply does not have the function of attenuating experiences, of making one feel more protected because reality with the encounter with the other is attenuated or reduced. I believe that in some cases it deprives precisely the possibility of this happening.

Let's take the case of a man who had a violent parent: are we sure that he would relive the sense of threat experienced with the parent by talking about himself through a computer rather than in his presence? I think not: for certain memories to be activated, situations must have sensory qualities that allow them to be retrieved. Similar considerations can be made with erotic transference.

Clinical vignettes

I report three episodes that seem to me to exemplify some of the issues reported. Let me premise, as you will have guessed from what I have written so far, that I have never treated any patient with the intention of receiving them exclusively by remote sessions. I only used this instrument exceptionally during the pandemic. After the end of the lockdowns, I have retained the possibility of doing remote sessions as and when needed, both in relation to pandemic situations and to situations related to patients' personal needs (not mine of course) health or otherwise. The vignettes I report, although expressed in the first person, relate to both my own work and that of some of my colleagues.

First clinical vignette (therapist is a woman)

The patient asks me for a remote session due to personal needs. In the remote session,he talks about his lover. The patient had only told me about this lover long after the beginning of the therapy. The time he talks to me about it (in presence) he does so with great difficulty.

The first time he talks about it, he states that not addressing this issue means not recognising the real reason why he asked to embark on a path. After talking to me about it, he does not take up the subject again. From the patient's associations and from his previous path with me, I sense that there are also aspects of erotic transference towards me. After the remote session in which he talks about his lover, when he returns to in-person meetings he does not take up the subject again.

It happens again that the patient asks for a remote session and, again, on that single occasion he talks to me about his lover. It becomes possible for me to read these movements of the patient as the need to attenuate the intensity of the erotic transference through remote sessions and to have a way to talk about his betrayals. It then becomes possible to share these contents with the patient in presence as well. This example reveals the transformative possibility of remote sessions. However, this possibility is only and only given by the fact that they are embedded in a well-defined framework of habitually in-presence sessions.

Second clinical vignette

The patient has covid and asks me to conduct the session remotely. He has been going through a long and heartfelt account of his romantic relationship for a few sessions. He shares with me some important content related to the end of it but then says that an aspect of this story he prefers to tell me the next time when he is present. At the next session he resumes the story and at the moment of telling me the passage he had preferred to keep in suspense, he bursts into tears.

The patient's wish, perhaps the need, was to cry in presence. Tears must be seen and heard, they cannot be conveyed by a screen. The patient needed to know that I was present there with him while he was crying. This patient's story is strongly intertwined with these contents: due to certain events experienced during his childhood he suffers from strong feelings of abandonment and loneliness.

Third clinical vignette

The patient has covid, which she contracted while her mother was at home with a serious illness. She writes me a message in which despite knowing about the possibility of seeing each other remotely (it had already happened) she prefers to skip the session. She assures me that she will pay anyway. I reply reiterating that I will still be available to connect if she wants.

At the next session, she tells me that her mother has died. Then I realise she died before the patient cancelled the session and that she could not do the session remotely to bring me this very important event. She tells me about two dreams.

In one she dreams that her mother wakes up, the patient in the dream thinks that this is not 'right', she tells her mother, as she told her many times when she was still alive, that she must rest. In the dream, she feels more and more uneasy until the patient looks into her eyes and does not recognise her.

In the other dream, she has an alarm clock in her hand that inexorably marks the passing of time. She knows that an apocalypse is coming, the world could end and instead of wasting time and running away, she goes to her room to collect the objects she wants to take with her. She tells me that in her room she keeps small objects that bear witness to her history and her past, for example, the pens she used in primary school, which she likes to keep to remember those times.

What strikes me in the two dreams is the contrast between the memory conveyed by a person who wakes up but does not recognise himself and the memory conveyed by dead objects that hold memories.

I will not dwell on the interpretation of these two very interesting dreams. However, I will merely note that in this case too the patient feels the need for presence to convey the importance of these dreams, and this seems to me to resonate with the theme of dreams between living-transformative memory and dead-fixed memory (remember that it is in the dream of memories conveyed by objects that the apocalypse, the end of the internal world, is coming).

Conclusions

As can be clearly seen from the vignettes, the tool of remote sessions can become very useful if placed in a framework of in-presence meetings. On the other hand, I have many doubts as to whether it can be considered an alternative and exclusive tool to psychotherapy carried out in presence.

In our work, we do not limit ourselves to providing counselling on the basis of the information we hear and integrate with our intellectual knowledge, but offer the possibility of hearing with the patient what we have not been able to grasp, process and transform so far. Only a meeting in person can make the possibility of this complete.