In this Q&A with the board of the British Journal of Psychotherapy (BJP), psychoanalyst Gillian Isaacs Russell, author of the 2015 book Screen Relations, discusses changes to the experience of psychotherapy brought about by the twin factors of the Covid-19 pandemic and the abrupt shift to “mediated communication” by phone or video conferencing (p. 1). Implicitly, the author writes from the standpoint that, beyond providing for continuity of care, there are no therapeutic opportunities inherent to technologically mediated treatment for either patient or therapist, and expresses the hope that “the value of co-present relating has been rediscovered and reasserted” (p. 10). This short review hopes to provide some element for patients and practitioners who wish to put this in perspective with their own experience.
Technologically mediated relationship is an “as-if” relationship
In the first part of this Q&A, Gillian Isaacs Russell describes how circumstances and her wish “to transcend space and time” brought her to start working online, and how, through the analysis of her own practice and extensive research she came to the position that it is “crucial to recognise the differences between embodied communications in a shared environment and mediated communication” (p. 2), which we understand, reading on, as more likely than not to be detrimental to patient, practitioner and treatment.
Indeed, considering the pre-pandemic trend in the practice of psychotherapy, she declares: “There has been a paradoxical drive to delete the body from the therapeutic interaction in the name of such things as convenience, democratization, continuity, and cost-effectiveness”. She regrets that: “we have been learning simply to accept simulated relationships, ‘as if’ relationships”, and issues a warning that, unlike her earlier self, we should not “sleepwalk into the use of technology for treatment” (p. 2).
Technologically mediated relationships can undermine core principles of therapeutic work
The sudden shift online was a forced choice which “found many of us unprepared and vulnerable” (p. 3). Gillian Isaacs Russell describes how, for example, the blurring of the boundary between work and home lengthened the working day by three hours for workers in the US and two hours in the UK, and how, amid the novel phenomenon of Zoom fatigue, there is “little time for silence, solitude and recalibration”.
The Q&A predictably comes into its own when the theme of intersubjectivity is broached. The author tells us, poignantly, that the disappearance of most non-verbal cues means that “online, we sometimes feel alone in the absence of the other”. Grounding her statement in recent research in neuroscience, she explains that online media create “a loss of presence” (p. 5) that affects our ability to ascertain whether or not we are experiencing the other as truly ‘outside’ of us, rather than a hallucination. This piece of research lends more weight to her earlier assertion that technologically-mediated relationships are ‘simulated’ or ‘as-if’. It would have perhaps been useful for her to make this link more explicit.
She also lists useful steps to take to mitigate the distracting effects of ‘partial attention’, such as turning off notifications on all devices and putting to sleep those that are not used during a session (p. 6), or ensuring that there is some time allocated on both sides of a session so that it is better committed to memory (p. 7).
When asked what may happen to “the core analytic principles of free association, evenly suspended attention and reverie” when treatment happens remotely, the author spells out what feels like a central aspect of her position, namely that “the ability to move away inside your own thought process and reconnect underlies a mutual ongoing sense of reliable presence that enables reverie. This is not always possible with the effort or anxiety of concentration that accompanies work with technology” (p. 5).
At this stage, and considering ample anecdotal evidence that this is an experience shared by many therapists and patients, it would have been very helpful if the author had tapped further into her understanding of the neurobiology of mediated relationships, and expanded on how she felt it affected phenomena like mutual regressions (such as described by Allan Schore), which are the focus of the most exciting new research, and which are increasingly seen as the implicit underpinning of the therapeutic encounter.
Indeed, informal reports by patients and therapists as well as my own experience suggest that, as the share of verbal communication proportionally increases when carrying out psychotherapy online, and as most of the physical cues are lost, affective attunement operates on a narrower range and sessions will tend to be more ‘left brain’ (i.e., mostly on secondary processes and rational operations) as a result. For some patients, this will feel less containing. For more resistant patients, it may offer an opportunity to engage more freely with a treatment that will appear less intense and threatening.
Psychotherapy and the perception of time and place
Building on her overall argument that vigilance is the only way to approach technologically mediated communications, the Interviewee then shares additional research that establishes the link between mental and physical functioning, namely that “the richer our embodied experience of acting and moving in space, the more profoundly it affects our perceptions, consciousness and memory” (p. 8). She adds: “the unchanging stasis of lockdown (what one person described to me as a ‘soup of experience’), without much movement in space or change in routine or environment, affects our memories and our perception of past, present and future”.
This is a very interesting point, and, if we go back to her assertion that remote work takes place in the context of an ‘as-if’ relationship, as well as to the point that she makes about the relative unreliability of the therapeutic container undermining core principles of therapeutic work, we may be left with the overall impression that a session of psychotherapy given remotely may become a fleeting moment, poorly committed to memory, of simulated relationship, based on an “illusion of presence” (p. 5), with limits on the reliability, extent and safety of communication.
So, should we even bother?
The Interviewee seems to be of the opinion that, despite the serious limitations of the medium, continuity of care is a good enough justification to consider offering treatment online or over the phone. She adds that that it is beneficial to talk about its technical limitations of with patients. In my experience, this is particularly helpful when it serves as a further exploration of existing issues such as powerlessness, intimacy and loss, that a patient may be working through.
Shared experiences both threaten and tighten the therapeutic relationship
This Q & A concludes with useful thoughts about how the shared experience of the pandemic and the advent of online psychotherapy as a mainstream practice challenge the traditional functions of patient and therapists when it comes to maintaining the boundaries of treatment and the safety of the therapeutic container.
In respect of the latter, she explains that “It is unreasonable to expect the patient to be able to provide a safe setting for themselves, if they have never had that basic experience of safety and cannot even imagine it” (p. 7). Gillian Isaacs Russell does not say how we can go about making provisions for this, or even if therapy itself can, in some cases, become an unreasonable undertaking.
It would have been beneficial for this Q&A to include questions about making decisions on continuity of care in cases where patients, who rely on a more primitive “defensive armoury” that includes “splitting, projective identification, denial and disavowal”, would be seen to struggle too much to engage with therapy in an environment that offers a narrower and looser framework for affect regulation.
When it is however possible to conduct psychotherapy under those new conditions, there is something that we may view as a silver lining: both the medium we now have to consider in delivering psychotherapy and the circumstances in which it has become indispensable seem to foster a levelling of the relationship – psychotherapy should indeed be a relationship of equals, where the therapist’s function does not confer status. Both patient and therapists are there to “bear witness to the realities of the world situation that we all share” (p. 8) while having the “very real shared experience of danger from an invisible intruder, uncontrolled and menacing, and perhaps literally existing in the other” (p. 6). As the nightwatchman in Albert Camus’ The Plague says:
“oh! If only it had been an earthquake! A good shake and that’s it. One counts the dead, one counts the living and the whole things over and done with. But this rotten bastard of a disease! Even those who don’t have it, carry it in their hearts.”
For better or for worse, whether we are ill or well, we are now very obviously ‘in this together’. It is my view that the loss of co-presence induced by the movement online of much of psychotherapy during the pandemic should be put in perspective with the benefit of introducing the need for a discourse on – or at least a mutual implicit recognition of – the fraternity of the therapeutic pair, of its shared vulnerability. The frailty of the act of relating is brought to the fore in a very potent way for both parties to psychotherapy, irrespective of their function. As the nightwatchman says, “they carry it in their hearts” and it is therefore an essential aspect of the transferential relationship.
There is also another important facet of the impact that technologically mediated work has on the therapeutic relationship that Isaacs Russell does not mention, which is that it can amplify certain aspects of the transference and countertransference. I gave a paper several years ago, based on a case study of “dual” online and offline work, highlighting how both the choice of ‘platforms’ and the experience of the work itself were consistent with the patient’s unresolved childhood issues. In the case I wrote about, technology had been brought in at the patient’s request to facilitate her travel patterns and, unconsciously, to create a relational context that was very well suited to the concreteness of her thinking about rootlessness, miscommunications and longing for presence.
In this Q&A, Gillian Isaacs Russell makes very interesting points, and her open question about the ‘realness’ of the online therapeutic encounter is vital to anyone involved in psychotherapy and needs keeping in mind. We can also only empathise with her longing for a form of normalcy to return as we reacquaint ourselves with the benefits of co-presence. It seems that she would like this to be a watershed moment in the rediscovery of what is essential about psychotherapy.
However this Q&A does not provide much food for thought to the practitioner or the patient who have a positive experience of technologically mediated work, and even though the media is deemed good enough by virtue of necessity, it is still perceived as a handy workaround rather than a bona fide means of therapeutic engagement.
The attitude of ‘making do’ may resonate with the motivational social discourse of wartime thrift and resilience while being consistent with much of the experience of remote work, but it is also born out of the conflation of a trend (the advent of technologically mediated communications) and a contingency (the global pandemic and the lockdown). The pandemic will end, but the means of overcoming some of the great difficulties it created for psychotherapy preceded it, as Gillian Isaacs Russell acknowledges (p.2) and won’t go away. We should, as a society and as individuals, heal from infection, illness and isolation, but we shouldn’t feel that a gradual – and partial – shift to technologically-mediated communications is something to recover from.
Psychotherapy is ultimately a never ending exercise in searching for the truth to one’s experience by means of a relationship. The status of co-presence as the only viable vehicle for this exercise has been challenged deeply in this pandemic, but the jury seems to be still out as to what the upshot of this challenge is going to be. Indeed, in contrast to the interpersonal grounding and subtlety that co-presence affords, technologically-mediated relationships may seem to be the flaky, concrete and clunky vehicle for the no less significant experience of co-absence.
But, limited as it may be, I would suggest that the experience that technology offers is not just contingent and derivative but a quintessential aspect of human relations. Language itself could be construed as a means of just making do with separateness and absence if we consider that, when we utter a word, we simultaneously invoke the reality of an object while acknowledging its intractable separateness from us. In using language, we soothe ourselves of the pain of absence as we enter into relationship, and the experience of receiving and providing psychotherapy online and over the phone offers just that.
The work of linguist Daniel Everett, whose field study of the Pirahã language is summarised in his book Don’t Sleep, There are Snakes, can be usefully referred to in an attempt to confer a “legitimacy” to the experience of relating through technology. Everett indeed describes how:
“There are five […] channels in Pirahã, each having a unique cultural function. These are whistle speech, hum speech, musical speech, yell speech, and normal speech—that is, speech using consonants and vowels”
Each channel is designed for use in certain circumstances: when out hunting, for example, whistle speech is best used, and nursing mothers will tend to use hum speech with their infants. These make for very different experiences of relating through language, and I would suggest that technologically mediated communications could be considered as a specific channel in any language, and not just a degraded form of communication.
If we take this view, while keeping in mind how this particular channel amplifies certain aspects of our shared experience while muting or cancelling out others altogether, we would feel compelled to challenge Gillian Isaacs Russell’s overall outlook, if not her research and clinical observations. Co-presence is indeed an essential, and perhaps central, foundation to a therapeutic relationship. This has been highlighted by how its total disappearance during lockdown has brought in sharp focus the need for a radical reengagement with the workings of psychotherapy.
Isaacs Russell seems careful not to push her point stridently, and her conservative position should be contrasted with the apparent humorous tone she uses to describe how she initially conceived of her own shift online as a means “to transcend space and time”. Maybe she acknowledges with good enough grace that psychotherapy online is still psychotherapy, but it will be for others to make the explicitly positive case.
1) Allan Schore: “The Growth Promoting Role of Mutual Regressions in Deep Psychotherapy”, lecture given in London, 2018 (nScience UK)
2) Alistair D Sweet, Elements of Psychotherapeutic Assessment and Treatment with structured and under-structured personalities, British Journal of Psychotherapy, 27, 1 (2011) 4-18
3) Albert Camus, The Plague, Penguin Modern Classics, (2002), p. 88.
4) Daniel Everett, “Don’t sleep there are snakes”, Profile Books, 2009, p. 185