by Amber Trotter, Psy.D.

ON TELETHERAPY AND RETURNING TO THE OFFICE

Par for the perpetually paradoxical course, this past year of COVID has been both stagnant and electric. Technology-mediated psychotherapy has been catalyzed, catapulted into a new dimension, questions about its limitations sidelined by more pressing matters.

I have felt deeply grateful for technology during the pandemic. I have always appreciated the associative freedom of the phone and have been moved by the emotional richness of video treatments. Part of my practice will likely remain remote. Good work is happening with patients I have never met in person. I have also been seeing patients in person throughout COVID, and it’s been interesting to compare notes. I want us to think about teletherapy from every angle: to be receptive, generous, critical, principled, cynical. Certainly, technology can reduce barriers to accessing care and yield unique clinical benefits. I maintain the value of being bodies together, and yet I struggle to articulate what precisely I find important. There are many variables at play, and many different situations. It can also be challenging to parse essential limitations of teletherapy from limitations of presently existing technology—or of technology in a particular circumstance. 

A central consideration is the extent to which the body is involved in thinking, feeling, and processes of personal change and growth. Teletherapy highlights questions about therapeutic action: are we coaching patients’ thinking or helping to physically regulate preverbal pain? Is the latter possible virtually? Would you tele-parent a baby? What exactly do we think we’re doing here? 

One theory I have is that being together in the flesh arouses the nervous system in a particular way. It raises the possibility of action. As Gillian Isaacs Russell observes in her excellent book on this topic, Screen Relations, you can’t actually fuck or fight in a technology-mediated session. Of course, you can’t ethically do so in an in-person session either, but the physical possibility is profoundly animating. It creates the tension that makes a good analytic treatment dangerous for both parties. 

Simulation entrapment presents another concern. Increasingly, in our technology-mediated lives, distinctions between inside and outside blur. A psychotic breakdown of consensual reality is visible everywhere, with implications for how we conceptualize teletherapy. I have been meeting biweekly by phone with my own therapist throughout the pandemic. I was years into treatment, on the couch, and the shift initially felt fairly insignificant. I knew his mind and presence well; we saw each other at analytic events—he felt very much a real person to me. Fourteen months later I’m not so sure. I lay down on my own couch, I slip my headphones in, his mind is clearly different from my own, but something ineffable has gone missing. A patient of mine, reporting on a virtual party she organized, conveyed this subtle psychosis succinctly: “It was great, really successful, everyone was engaged and having fun. I had fun. And then it was over and I closed my screen and I sat there alone and I just felt strange and crazy and I was like, ‘wait, did that actually happen?’”

More broadly, it is worth noting that the decision to use digital technology is not neutral. We too often dissociate sociopolitical and economic context from conversations about technology—especially in the context of psychotherapy. Yet the digital revolution is the result of powerful political and economic forces. Digital technology has become part and parcel of corporate capitalism, now mining human attention, emotion, and behavior in the service of profit. There’s a lot of capital being devoted to figure out how to get us to use technology more and more, and in increasingly intrusive, manipulative ways. As a disciple of the dictum “the personal is political,” I hope we can at least consider teletherapy in a sociopolitical and economic context. 

I am decades deep into a polemic writing style. It is easy to moralize at abstract distance. On the ground, balancing the gamut of ethical, clinical, esthetic and material concerns, I find questions about technology nuanced and challenging. I look forward to continuing to discuss them analytically together.