Psychoanalysis over the Internet

PSYCHOANALYSIS ON THE INTERNET: A Discussion of its Theoretical Implications for Both Online and Offline Therapeutic Technique

Paolo Migone, MD Psicoterapia e Scienze Umane, Parma, Italy

Psychoanalysis over the Internet is discussed as a means of reflecting on the way we think about theory of technique generally, and on what we mean by “communication” between patient and analyst. The way we think about online therapy has direct implications for the way we practice “offline” therapy. This problem is discussed from the point of view of the history of the theory of psychoanalytic technique, with reference to the classic 1953 paper by Kurt Eissler (K. R. Eissler, 1953, The effect of the structure of the ego on psycho- analytic technique, Journal of the American Psychoanalytic Association, Vol. 1, pp. 104–143) on “parameters,” and also with reference to the redefinition of psychoanalysis itself in terms of the analysis of the transference by the late Merton Gill (e.g., M. M. Gill, 1984, Psychoanalysis and psychotherapy: A revision, International Review of Psychoanalysis, Vol. 11, pp. 161–179). Online therapy is simply a different therapy, in the same way as two therapies, both offline (or both online), may be different from each other. The fil rouge that runs through this paper is a reflection on the very identity of psychoanalysis.

Keywords: Internet psychotherapy, Internet psychoanalysis, online psychother- apy, theory of psychoanalytic technique, parameters of psychoanalytic technique

It is a commonplace to say that the Internet is changing the way we communicate, and also the way we live, with repercussions that are not easily foreseeable. The worldwide web (www) is penetrating into every corner of our life, gradually changing ourselves and itself as it becomes more and more sophisticated in order to meet the most diversified needs. The importance of the Internet has been compared to the revolutionary discovery of the printing press.

Here I will take into consideration only one of the many possibilities the Internet can offer, namely as a vehicle for psychoanalytic therapy. But this paper will not deal with the

The author thanks Morris N. Eagle and John Kerr for their help in revising this paper. Correspondence concerning this article should be addressed to Paolo Migone, MD, Via

Palestro 14, 43123 Parma, Italy. E-mail: migone@unipr.it

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Psychoanalytic Psychology © 2013 American Psychological Association 2013, Vol. 30, No. 2, 281–299 0736-9735/13/$12.00 DOI: 10.1037/a0031507

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clinical aspects of Internet therapy (a literature already exists in this regard). It will deal, instead, specifically with the theoretical implications of both online and offline therapy for therapeutic technique, and in order to do so it will necessarily discuss also the differences between the two therapeutic settings. It is argued that the way we think about online therapy has direct implications for the way we think and practice traditional, “offline” therapy. In other words, this paper will not deal with the question of therapeutic action or with the validity of online therapy. Internet therapy is only taken as a pretext—an excuse, so to speak—in order to reflect on theory of psychoanalytic technique in general, and also on the identity of psychoanalysis versus psychoanalytic psychotherapy. It should be clear that this paper is not a plea for the practice of psychoanalysis online. Rather, it aims at encouraging a reflection on theory of technique. Psychoanalysis on the Internet is not discussed as such in this paper, but serves as a reference point to consider theory of technique, in particular the way we conceive “communication” between patient and analyst.

Psychotherapy on the Internet has been referred to in many ways; for example, as online psychotherapy, telepsychotherapy, e-psychotherapy, etc., and it is a phenomenon that is rapidly growing. There are more and more web sites for counseling or for online psychotherapy, studies on the efficacy of this practice have been carried out, and so forth. In recent years, several psychoanalysts involved with the China American Psychoanalytic Alliance (CAPA, http://www.capachina.org) are experimenting with teaching, supervi- sion, and therapy with Skype to Chinese colleagues with the aim of helping the growth of psychoanalytic practice and culture in that country. (For discussions on the psychological implications of the Internet and on the interface between the Internet and psychoanalysis, see, among others, Turkle, 1985, 1995; Wallace, 1999; Bird, 2003; Akhtar, 2004; Ormay, 2006; Malater, 2007; Monder, Toronto, & Aislie, 2007; Dini, 2009; Cairo & Fischbein, 2010; Scharff, 2012; see also “Special issue on the Internet,” 2007, Vol. 94, Issue 1, The Psychoanalytic Review).

Technical Aspects of Internet Communication

The Internet allows us to connect and communicate with people who may live in any corner of the world at a very low cost, virtually for free, or, at worst, at the price of a local phone call. One may object that this happenstance is not altogether new, since the telephone already made this possible. In fact, in the United States the issue of “telephone analysis” was discussed at least as early as the 1950s (e.g., Saul, 1951). Commentators have variously considered telephone analysis a useful way to overcome certain resistances or impasses in the analysis, to replace missed sessions, to save time and reduce travel expenses in the case of long distances or when a patient’s handicaps limit movement, and when either patient or analyst move to another city and the parties do not want to interrupt an ongoing analysis.

What the Internet can offer, compared to the telephone, is the opportunity for a video-conference (e.g., with Skype). Thanks to so-called virtual reality, it is possible to simulate the session almost exactly. There are those who even simulate the waiting room. With audio and video synchronized in real time, it is possible also to duplicate the timing of interventions, silences, the length and times of scheduled “sessions,” and various other rituals as if both partners were in the office. Concerning privacy, sophisticated programs (such as those used by Internet banks) may encrypt communications (this is true especially

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282 MIGONE

with Skype, considered to be secure in computer-to-computer communications1), and ethical codes for Internet have been suggested (e.g., see American Psychological Asso- ciation, 1997; Manhal-Baugus, 2001; Heinlen, Welfel, Richmond, & O’Donnell, 2003; Mora, Nevid, & Chaplin, 2008; Fitzgerald, Hunter, Hadjistavropoulos, & Koocher, 2010). Nonetheless, in many respects, Internet psychotherapy can be considered a variation of telepsychiatry or even telemedicine, both of which have been experimented with for a number of years in order to reduce costs in countries such as Australia, where there are often formidable distances intervening between doctors and patients (e.g., see Dongier, 1986; Preston, Brown, & Hartley, 1992; Baer et al., 1995; Kaplan, 1997, 2000; Brown, 1998; Gammon, Sorlie, Bergvik, & Hoifodt, 1998; Gelber & Alexander, 1999; Zaylor, 1999; Simpson, 2001; Taylor & Luce, 2003; Hilty, Marks, Urness, Yellowlees, & Nesbitt, 2004; Bauer, Wolf, Haug, & Kordy, 2011; Wolf, 2011).

Video-conferencing (e.g., with Skype, which is widely used) is not the only way of Internet communication; there are other modalities that are quite different. These modal- ities are distributed along a continuum of types of human communications, and they should not be lumped together, because each has its own specific characteristics that shape the therapeutic interaction—in the same way as, for that matter, various “normal,” offline therapeutic situations have their own characteristics that shape the interaction. For example, another possibility for therapeutic interchange is constituted by the written communications of e-mail or chat (the latter is in real time). Actually, these forms of written communication seem to be more widely used as methods for Internet therapy or counseling, perhaps because they do not require any special technical arrangements beyond an ordinary personal computer (incidentally, we should not forget the widespread use of SMS [short message service] with cellular phones between patients and analysts). Other commonly used modalities are discussion lists, forums, and blogs or self-help groups, where—in a way analogous to groups such as, for example, Alcoholic Anony- mous—more people can interact and talk about common themes, or else can simply listen (“lurk”) and profit from what others say (for an overview, see Houston, Cooper, & Ford, 2002).

It may be worthwhile to spend a few moments on the differences between written and oral communication before proceeding (Migone, 1998b). The enormous diffusion of communication by e-mail may represent a veritable return to the era of correspondence through letters, an era which had disappeared with the advent of telephone. But upon reflection, e-mail is similar to hand-written letters chiefly in one respect; namely, the fact that one has to write down what one wants to say, inducing, due to the slowness of the process, a different emotional and reflexive disposition. To be sure, this putative slowness is true especially of hand-written letters, as writing with a keyboard is invariably much faster. Moreover, thanks to word processing, the process has been speeded up further, for

1 According to the Handbook of China American Psychoanalytic Alliance (CAPA), “Skype is encrypted using a proprietary code that has never been released by the developers, despite substantial pressure on the part of many powerful public entities. . . . It is nearly impossible to detect not only the contents of the conversations, but also their existence. . . . Apparently, Skype is so safe that criminals can speak using it, and the police cannot listen in—and this is Interpol, not just some local cops. Skype has been able to reject court orders to decrypt, because its central offices are in Luxembourg, and thus protected from the EU confidentiality laws (Skype was developed in Latvia). However, . . . all the comments on security discussed above apply to the computer-to-computer communications. The paid features of Skype and texting—are not secure» (Buckner, 2011, p. 13, italics in the original text).

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283PSYCHOANALYSIS ON THE INTERNET

it is now also possible to review the text and erase “errors” or simply to delete text with great rapidity. To be sure, it was always possible to recopy a letter with changes or even tear it into pieces and throw it into the wastebasket, with the option of retrying it on another day. Yet editorial changes on written letters generally take more time.

An important difference between e-mail and surface mail (“snail mail”) is the trans- mission speed, which is close to real time with e-mails (they can reach their destination within seconds or minutes) and very slow for surface mail (days). This arguably creates a sense of immediacy in sending an e-mail that a regular letter—even if it is by special post—lacks. But this immediacy is offset by the fact that with e-mail it is difficult or impossible to communicate other meanings except the content itself, which is privileged at the expense of nonverbal or analogical communication. Not only it is impossible to see the facial expressions and to hear the tone of voice, as in face-to-face contact, but it is clearly impossible in e-mail to see personal calligraphy, except for the style allowed by word processing; namely, choice of font, capital letters (as in screaming), italics, bold (in programs that allow this), and “emoticons” (a well known term that means emotions symbolized by icons, e.g., using parenthesis for the mouth, colons for the eyes, etc.). Whether for these reasons, or due to the sense of immediacy of nearly real-time commu- nication, or because of a vague ancestral tie to that forerunner of all e-mails—the memo—people do not ordinarily put into their e-mails anything like the concentration, circumspection, or art they once put into their letters. That is not to say they couldn’t if they chose. And to this must be added the pertinent comparison that people have never put the same level of concentration or art into their conversation—except in diplomatic situations and in salons, where it is expected. Yet this lack of art in conversation obviously does not prevent psychotherapy from taking place, any more than letter writing necessarily either enhances it or prevents it. For the record, the first historical example of “psycho- analysis by letters” could be considered the correspondence between Freud and Fliess, as several historians of psychoanalysis have pointed out.

Why Is Psychoanalysis on the Internet Interesting?

In the introduction above, I have discussed the technical aspects of various ways of Internet communication, and it should be repeated that they are quite different from each other, since each one has its own peculiarities that shape the interaction. Let’s focus now specifically on psychoanalysis on the Internet, and let us ask why it might be interesting. In this regard, I want to make clear, as I emphasized before, that I am not fundamentally interested in online analysis per se, even though in some cases I have practiced it, as have others. What has always been of great interest to me, indeed has been fascinating to me, is the way some colleagues have faced and discussed the issue of online psychoanalysis, how they have addressed themselves to this “new” object, and especially their way of seeing similarities and differences with “traditional” (i.e., offline) psychoanalysis. I have been particularly intrigued by their claims to be either in favor or against online psycho- analysis and their reasoning. What has fascinated me was the logic behind this endorse- ment or disavowal as the case may be.

In my view, online psychoanalysis is interesting because it forces us to reflect on what it is not; that is, traditional psychoanalysis. The way online psychoanalysis is discussed is revealing of the way psychoanalysis without Internet could be conceived and practiced, and especially of what we mean by “communication” between patient and analyst. In particular, I will try to show in detail the danger of relying on a stereotyped understanding

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