SOME EFFECTS OF NEW TECHNOLOGIES<\/b><\/p>\n
ON PSYCHOANALYTIC WORK<\/span> AND IDENTITY<\/span>*<\/b><\/p>\n By Andrea SABBADINI<\/b><\/p>\n <\/b>‘The doctor should be opaque to his patients’<\/i>, writes Freud, ‘and, like a mirror, should show them nothing but<\/span> what is shown to him<\/i>’ (1912, p. 118). The principle of keeping ourselves as private and neutral as possible by not disclosing anything personal about ourselves – be it of a biographical or emotional<\/span> kind – is justified by the view that the exploration of our patients’ fantasies about us is more relevant than objective reality<\/span> to the analytic process. Their imagining us of a certain age, marital status, country of origin, sexual orientation<\/span>, professional status, political views or religious faith<\/span> is more important than the so-called objective truth<\/span> about such matters.<\/p>\n When patients ask us direct personal questions we would usually not answer them, but<\/span> instead explore the reasons behind their curiosity, as well as what they imagined the state of things to be, without then needing to confirm or disconfirm the accuracy of their guesses. This attitude has traditionally been considered as essential to the development<\/span> and analysis<\/span> of the transference<\/span>. In the counter-transference we may feel affected both by the specific quality of our analysands’ curiosity (it may upset<\/span> me that this patient should be so keen to know whether my parents are still alive) and by the accuracy, or otherwise, of their fantasies: I could feel amused by a patient being convinced that I am a deeply religious man, or moved by another correctly guessing from the tone of my voice that something was troubling me at the time.<\/p>\n While adherence to the principle of abstinence<\/span> (desires expressed by patients in the course of psychoanalysis should be interpreted rather than acted upon) remains paramount in our practice, our belief that we could maintain total privacy and neutrality<\/span> is the result of unrealistic wishful thinking<\/span>: we would be blind not to recognize that patients have always been able to find out, or at least to infer, much about us, by using as sources our physical appearance and clothes; consulting-room address and furniture; information from other<\/span> patients, colleagues or friends; reading the analytic literature or attending public lectures, if not also building their knowledge about us upon their experience of our attitude towards them and unconscious<\/span> counter-transference enactments.<\/p>\n In the current age of new communication<\/span> technologies, the internet has wide-opened access to information about others, analysts included. Many patients nowadays would not think twice to ‘Google-up’ their therapists’ name and find information about them (that some of it might be inaccurate – one of my patients believed that I was a well-known photographer who happens to be my namesake – is beside the point). In Glen Gabbard’s words such easy access to all sort of personal information ‘has hammered the nails in the coffin of analytic anonymity’ (quoted by Vinocur Fishbein 2010, p. 986). While analysts should resist the temptation of ‘Googling-up’ their patients in order to find out about them from the internet rather than from the couch<\/span>, we cannot expect our analysands to behave with a similar self-discipline. And why should they? If information about ourselves, correct or otherwise, is made available to the public, we have no saying (and, indeed, no right) in preventing our patients to access it – indeed, we shouldn’t even advise them against doing so. What we should do instead is to help them explore the reasons behind their searches, what they expect to find out, and what such personal information about us may mean to them. The object<\/span> of our analytic inquiries is then how such electronically-acquired new knowledge has affected them (impressed, angered, pleased, disappointed, reassured or surprised them) – and why.<\/p>\n It is worth remembering here of the difference<\/span> between the active searches that some, perhaps most, patients may make about us with the help of the internet and our volunteering personal information about ourselves to them, or answering their direct questions, which, now as much as in Freud’s times, I would still consider as inappropriate technique<\/span>. So-called analytic self-disclosure<\/span> in not an option. I wouldn’t keep photographs of my children in my consulting room<\/span> even if I well know that my patients could find their pictures posted on social media.<\/p>\n This massive change in the public availability of personal information involves major transformations to our analytic work<\/span>. In particular, it affects our own sense of professional identity<\/span>. Being cautious about which information about ourselves we deliberately make available online may be a helpful precaution. I consider it unwise to have our own website in order to publicize our trade (as many colleagues do) or a Facebook account to manage our social life, or to ‘Twitter’ our comments about current events to our followers. Such cautions, however, only have a marginal effect for we ultimately have a limited control over what gets out on the internet. Any of our publications, participation to conferences, academic engagement, etc. will automatically expose us to anyone interested to find out about us what we would not otherwise voluntarily disclose.<\/p>\n One of my patients, a young man, found out that from ‘Googling-up’ my name that I had published a book. He bought it and then looked up the names of the people in the dedication page, guessing that they could be my relatives, and then found out more about them from Facebook… On the one hand I found all this disturbing as it made me feel exposed and vulnerable, but<\/span> on the other<\/span> I was pleased that this man had had enough trust in the analysis<\/span> to feel free to confess his voyeuristic and ‘online stalking’ activities – something which, incidentally, he felt guilty about. This allowed us to explore important aspects about the origins and meanings of his curiosity; he had grown up with parents who were revealing age-inappropriate details about their sexual<\/span> lives to their young son, but<\/span> at the same time depriving him of vital bits of information about the family, thus indirectly encouraging his exciting or frightening fantasies. As a result this man had developed a florid curiosity – useful in the pursuit of his scientific studies, but<\/span> disruptive<\/span> of his personal relationships – and an important aspect of his transferential relationship to me.<\/p>\n In the course of the past four decades we have seen an invasion of new technological tools in the field of communication<\/span> and information, from the first bulky answering machines on our desks, to today’s sophisticated smartphones in our pockets. We could not have predicted, however, the extent to which these developments would affect<\/span> our psychoanalytic work<\/span>: in the area of research with the help of large databases of information and in our clinical activities. In particular the easy and ever-faster access to the internet since the late 1980s has revolutionized the way in which we operate as psychoanalysts, the way in which we relate to our patients (and they to us) and, as a corollary, the way in which we conceive of our professional identity<\/span>. We are no longer the same psychoanalysts of a few decades ago, even if we still hold on to the same fundamental principles.<\/p>\n The impact of information and communication<\/span> technologies is felt by all psychoanalysts and psychotherapists, including those who may be unable or unwilling, for a variety of reasons, to make much use of them. I consider such an impact on our work<\/span> to be fundamentally positive. Although some aspects of it are a source of concern<\/span>, for instance<\/span> the increased difficulty to preserve the confidentiality of clinical material<\/span>, I believe that those in our profession who object<\/span> in principle to technological progress, like the Luddites had done in the 19th<\/sup> century textile industry, are self-defeatingly destined to be left behind. But<\/span> especially in these first decades of the electronic revolution there is a price to be paid for it, often before we can make available to us the intellectual<\/span> and emotional<\/span> resources to pay it.<\/p>\n In the course of a couple of generations everybody has had to familiarize him or herself (some more successfully than others) with a vast number of new words, ideas, objects and activities. A large, but<\/span> steadily dwindling, population of what Prensky (2001) has called ‘digital immigrants’ has thus come into existence – those who, myself included, grew up before the new electronic technologies, in contrast with the new generation of ‘digital natives’, familiar since childhood with the language of computers, video-games and the internet, and more comfortable than most of us with establishing and maintaining relationships from a distance through social networking sites. Who nowadays still remembers having had a ‘pen friend’? Such a process has involved a loss<\/span> of competences and the need<\/span> to replace them with alternative ones. Because of the speed of the electronic revolution, these enforced changes and readjustments have often been experienced as traumatic<\/span>, including by psychoanalysts. A number of unconscious<\/span> defenses, such as denial<\/span>, have been mobilized to deal with the confusion thus engendered in our sense of professional identity<\/span> (see Lemma – Caparrotta, eds. 2013).<\/p>\n <\/b>About a year ago I received an email from a Mr D. He was asking for a consultation<\/span> because he had decided, as he put it, ‘<\/i>to <\/i>embark on an analysis<\/span>’. I replied by giving him my mobile telephone number so that he could call me up to make an appointment – which he did. Several SMSs from him followed – to change the date of our meeting because he had suddenly decided to take a holiday, to confirm my address and the new date of the consultation<\/span>, etc. Having finally arrived on the right day, at the right time and in the right place, Mr D called me up again from outside my front door to check that the bell he was going to ring was the right one.<\/i><\/p>\n In the course of the consultation<\/span> Mr D confessed that he had already ‘Googled me up’ and was pleased to have discovered that I had published articles on cinema and psychoanalysis as he had himself a great interest in films. He also informed me that he would be available to attend only one weekly session<\/span>, something which, as I explained to him, I was not prepared to do for I see my patients more frequently. Mr D insisted that it was me he wanted to see. As I could not comply with his request, I referred him to a colleague – something which, feeling rejected by me, he only reluctantly accepted.<\/i><\/p>\n A week later I received an email from Mr D with a link to a website: the advertisement of a company offering discounted Viagra, Cialis and other<\/span> such pharmaceutical products. Having overcome my initial surprise (and, I must add, considerable annoyance), I reasoned that Mr D must have felt powerless to obtain from me what he wanted (‘embarking on an analysis<\/span>’) and projected his own impotence<\/span> onto me, to then present me with a cheap chemical solution to ‘my’ problem.<\/i><\/p>\n None of this – contacting me by email, leaving SMS texts, checking my credentials on Google, sending me a link to an internet website – could have happened only a few years ago. The specific use made of such electronic means of communication<\/span> may be idiosyncratic to Mr D, but<\/span> their ubiquitous presence, one way or another, for better or for worse, affects us all.<\/p>\n I will now consider which changes to our classic setting<\/span> are required to allow psychoanalytic supervision<\/span> or therapeutic sessions to be carried out with the help of electronic devices; how our attitude towards supervisees and patients may be altered by such changes; and how our own sense of who we are (what we believe in – and what, why and how we do it) is influenced as a result – to such an extent, perhaps, that our analytic identity<\/span> may end up being transformed also when we happen to resume working in our more conventional ways.<\/p>\n For many years now psychoanalysts have been engaging in telephone supervision<\/span> and analysis<\/span> (Bassen 2007; Leffert 2003; Zalusky 2003). At first this was done in order to deal with the problem of candidates living too far away from any training analysts for attending sessions in person, sometimes because a recognized Psychoanalytic Institute did not exist yet in their own countries; the only way for these candidates to train was therefore to do so from a distance, i.e.<\/i> over the telephone. This practice, sometimes referred to as ‘teleanalysis’ (Scharff 2010) or ‘distance analysis<\/span>’ (Carlino 2010), was extended to situations where either patient or analyst<\/span> had to move abroad or to a different city for work<\/span> or family reasons (a development<\/span> made more impelling by the increasingly frequent phenomenon<\/span> of geographical mobility) and the only way for the analysis<\/span>, originally taking place in the consulting room<\/span>, to continue was to conduct it over the telephone. In these cases, sometimes the analyst<\/span> recommended that meetings in person would also take place, if only sporadically, so that the two participants in the analytic couple could remind themselves of what it feels like to share the same physical space. On a more short-term basis, telephone meetings would replace the conventional ones when patients undergoing analysis<\/span> became affected by an illness or had to move temporarily to a far-away place for work<\/span> reasons, thus being prevented to attend their sessions in person.<\/p>\n All these situations have persisted over time and, from what can be inferred from the relevant literature and from informal conversations with colleagues, have in fact become more frequent as well as acceptable to a growing number of practitioners. In the last few years, though, and because of the spreading of free and user-friendly video-conferencing facilities, distance psychoanalysis has also been used as the practice of choice rather than of necessity, with patients opting for meeting in cyberspace<\/span> even when they could have easily done so in the consulting room<\/span> – a questionable practice because of the likelihood that its main purpose is to circumvent resistance<\/span> to the in-person analytic process.<\/p>\n The ever-more common practice to conduct psychoanalytic and supervision<\/span> sessions by telephone, video-calls or even email (Gabbard 2001; Carlino 2010), has been a source of considerable debate. Some authors would claim<\/span> that ‘the present state of modern telecommunications… must be taken as a new opportunity to allow for the implementation of analysis<\/span> beyond the walls of the psychoanalyst<\/span>’s office’ (Carlino 2010, p. 3), thus much increasing its accessibility. Others would find it ‘difficult to accept the argument that psychoanalysis, or we psychoanalysts, have to chase after the changing times and society<\/span>. Our task<\/span>’, they point out, ‘is to understand and interpret change’ (Argentieri and Amati Mehler, 2003, p. 18), while others remind us that ‘there is a tendency in current discussions of “virtual reality<\/span>” to forget Freud’s observations on “psychic reality<\/span>”, that one’s view of “reality<\/span>” is invariably coloured and organized by one’s individual psychology and unconscious<\/span> wishes. An irrational<\/span> dread of the “virtual” in cyberspace<\/span> has led some analysts to a naïve, concrete, and essentially non-psychoanalytic view of the “real”’ (Freeman, quoted in Stevens 2014, p. 1109).<\/b><\/p>\n I shall limit myself here to explore some of the implications for the analytic setting<\/span>, attitude and identity<\/span>, of sessions carried out by Skype, and shall introduce the neologism ‘Skypanalyis’ to refer to such practice. Skype is the video-conferencing software programme that allows those engaging in conversation to also watch each other<\/span> on their respective computer screens. Free, easily accessible and simple to use, Skype is a more sophisticated means of communication<\/span> than the telephone, more compatible with our conventional ways of practicing psychoanalysis and, besides, more likely for these reasons to become widespread. In order for you to know how the other<\/span> will see you (e.g.<\/i> whether your face is contained<\/span> within the frame), Skype also shows your own image in a corner of the screen<\/span>: a small mirror, in effect, which may acquire special significance in the context of the therapeutic setting<\/span> where normally, in the absence of mirrors, people cannot see themselves.<\/p>\n Should the conventional analytic setting<\/span> of couch<\/span> and armchair be somehow replicated when sessions occur by video-call? Should Skypanalysis be set up in an asymmetrical way, so that the camera is trained on the patient’s body (allowing the analyst<\/span> to see him), but<\/span> not on the therapist<\/span>’s? The analyst<\/span> would then be sitting in her consulting room<\/span>’s chair with her laptop in front of her showing the analysand<\/span> on the screen<\/span>, while the patient would be lying down on a couch<\/span> in his own home like what he would have done if he were in the actual<\/span> presence of his therapist<\/span>, perhaps with the webcam placed behind his head to give the analyst<\/span> a similarly limited view of him. Such an artificial setting<\/span>, mimicking the more usual analytic one, can easily lead to distortions in transference<\/span> and counter-transference dynamics, and be utilized for unconscious<\/span> or preconscious<\/span> acting-out purposes. Perhaps a preferable arrangement would be for therapist<\/span> and patient engaged in Skypanalysis to sit in front of their computers with both webcams switched on, thus reproducing the face-to-face setting<\/span> of most analytic psychotherapies – not an ideal arrangement, of course, but<\/span> a worthy compromise<\/span> if it allows the work<\/span> to take place at all between participants otherwise living too far from each other<\/span> to meet in person on a frequent basis.<\/p>\n For what concerns the setting<\/span>, distance analysis<\/span> would require, not unlike the classic one, the rigorous preservation of constancy and consistency<\/span>. The analytic contract, preferably stipulated in the course of an initial in-person interview in the psychoanalyst<\/span>’s consulting room<\/span>, should specify not only such details as the amount and form of payment of fees, but<\/span> also that sessions take place at regular times and intervals, and with both analyst<\/span> and analysand<\/span> engaging in telecommunication with each other<\/span> from a constant<\/span> location, e.g.<\/i> sitting for every session<\/span> in the same room. Mutual trust from both participants is essential for the implementation of such basic rules.<\/p>\n It is worth noticing that the communication<\/span> tools needed by both participants for engaging in distance analysis<\/span> (computers, webcams, internet connection, Skype software, etc.) and the activities required for activating them (such as ensuring access to the internet, and for the analysand<\/span> to make the call at the agreed-upon time) all become part of the new setting<\/span>; as such, both their presence and the ways in which they are being utilized are likely to affect<\/span> transference<\/span> and counter-transference dynamics, and therefore become a potential focus of interpretations. The boundaries<\/span> surrounding this virtual setting<\/span> are inevitably different from those present in physical space, even if their main function<\/span> of protecting the analysis<\/span> from external intrusions remains the same.<\/p>\n Tele-conference technology, at least in its present state, is far from flawless: for instance<\/span>, the sound of the voices may become distorted or lose its synchronicity with the images, and the video may at times freeze. Furthermore, if in the course of a session<\/span> the internet connection on either side gets interrupted, the communication<\/span> (and therefore the session<\/span>) is also discontinued – a not infrequent and frustrating occurrence. Which fantasies are then likely to be activated? Was the interruption deliberate? Will it be restored, and if so when? Which changes to the setting<\/span> should be brought about to deal with it? Should the time which had been missed out for analytic work<\/span> during the interruption be made up at the end of the session<\/span> for it to have lasted its full fifty minutes?<\/p>\n Related to these issues, at least as far as the fantasies that could be evoked are concerned, is the often-encountered occurrence of silences in the course of a session<\/span>. When the two participants in the analytic couple communicate from a distance, silence<\/span> on either side can feel more difficult to tolerate than it would if they were in the same room. This is because silence<\/span>, especially if visual contact is not available, may be experienced as threatening, making it more likely to get broken prematurely in an attempt to prevent the emergence of anxieties of abandonment<\/span> or persecution<\/span>. These can take the form of paranoid<\/span> fantasies such as doubts about whether the other<\/span> person is really being silent or has instead left the room, got distracted<\/span> doing something else, or even perhaps dropped dead… Poland pointed out that patients in his office ‘sometimes ask “Are you asleep<\/i>?” but<\/span> on the phone they ask “Are you there<\/i>?”’ (quoted by Bassen 2007, p. 1034).<\/p>\n Another consideration is that, unlike in sessions taking place in a consulting room<\/span>, during video-calls the bodies of the two participants only share a virtual space, also known as cyberspace<\/span>. There is no doubt that the physical presence of the analyst<\/span>’s and the analysand<\/span>’s bodies play<\/span> an important part in their interaction, with repercussions on the transference<\/span> and counter-transference. Is it then possible to thus dispose of bodies, or rather of their actual<\/span> presence in a physical space, without this having major implications on the analytic process? How will their absence alter<\/span> the quality of the communication<\/span> between the analytic couple – indeed, any couple? It is true that patients using the couch<\/span> have only a few brief moments to look at their analysts at the beginning and the end of sessions, and analysts sitting in a chair behind their patients have only limited visual access to their bodies. It is also true that physical contact between them is mostly non-existent<\/span>, and that other<\/span> perceptual modalities (such as smell<\/span>) only rarely come to play<\/span> a significant part in the analytic relationship. However, the mere possibility<\/i> of, say, bodily contact between them, be it of an erotic, affectionate or aggressive nature, is central to the experience (both actual<\/span> and transferential) that therapist<\/span> and patient have of each other<\/span>. The absence of such possibility in Skypanalysis, therefore, is not a matter of indifference.<\/p>\n We may add that, while in distant analyses the two bodies are not simultaneously present in the same location, in this virtual space shared by analyst<\/span> and patient there is now a third presence replacing, as well as representing, them: that of the electronic apparatus<\/span> (computers with their microphones and webcams) which, at least in the first few sessions before those using them get accustomed to it, cannot but<\/span> disturb the intimacy<\/span> and privacy of the analytic relationship. This interference will often have disturbing connotations, including in the area of Oedipal<\/span> fantasies, possibly stimulating curiosity, jealousy<\/span> and persecutory anxieties. None of this, it could be argued, is a bad thing in itself, but<\/span> it does require careful handling<\/span> and interpretation<\/span>. In this respect Yamin Habib comments that ‘the analyst<\/span>’s acceptance of the involvement of a permanent third party in the relationship – even if the third party is an instrument – modifies the conventional setting<\/span> so drastically that it is appropriate to consider whether the resulting process diverges substantially from psychoanalysis as such<\/i>’ (2003, p. 26, my emphasis).<\/p>\n The answer to this question, it seems to me, depends on our definition of ‘psychoanalysis as such’. Back in the distant year 2000, in response to an article by Dinitia Smith (2000) in The New York Times <\/i>pointing out that many American analysts, in the name of openness, conduct psychoanalysis by e-mail and by videophone, I commented: ‘If we do not draw a line somewhere, we shall end up practicing a profession which may be thriving, but<\/span> is no longer psychoanalysis’ (Sabbadini 2000). I still believe that a line may need<\/span> to be drawn but<\/span>, fifteen years on, I am less certain as to where<\/i> it should be drawn.<\/p>\n It is crucial to acknowledge that relationships and communication<\/span> taking place in cyberspace<\/span> are fundamentally different from those happening in physical space. Any denial<\/span> of such differences and attempts to reproduce the classic setting<\/span> in the kind of virtual reality<\/span> where distant sessions occur are doomed to failure. For instance<\/span>, the importance of the temporal dimension in psychoanalysis, and the peculiar coexistence of its timeless quality with the presence of rigorous time boundaries<\/span> (Sabbadini 1989) is even more prominent in Skypanalysis: this is because the same fifty-minutes shared by the two protagonists on such a psychoanalytic stage replaces, so to speak, the physical time they would have occupied had they engaged in classic analysis<\/span>. As Carlino notices, a feature of distance analysis<\/span> is that ‘analytic dialogue… is measured from communicational parameters of time… and not in patterns of geographic distance’ (2010, p. 64).<\/p>\n On the other<\/span> hand, the assumption that only the conventional way of carrying out analysis<\/span> is the correct one and the one most likely to bring positive therapeutic results simply because it is what we are used to, is questionable. In her report on an IPA panel on these issues Savege Scharff wrote about teleanalysis: ‘psychoanalysis is primarily the encounter with an understanding mind in whatever setting<\/span> that may occur<\/i>’ (2010, p. 990, my emphasis). The evidence built on over a century of psychoanalytic experience suggests that changes to the original setting<\/span>, as long as they respect certain basic parameters, can be advantageous to both analysts and patients, should be welcome whenever their enforcement improves the quality of the