The ‘Both-And’ with Teletherapy and Teleanalysis

Todd Essig

October 2021, nineteen months into the pandemic and I’m still working full-time as a telehealth provider. Sitting now and writing in front of a full-color HD screen fed by a super-fast internet connection, I worry about what comes next: Will APsaA, and psychoanalysis, embrace a research-grounded and nuanced both-and approach to using technology, one that acknowledges both what is possible and what is not? Or will a more one-sided enthusiasm take hold? Will we take full measure of technology’s significant promise and its inevitable losses and limits? Or will an either-or mindset of being for or against technology blind us to what screen relations can’t do?

Screen relations weren’t always like they are now. My first technologically mediated relationships were way back when screens were monochrome and modems so slow that one could type faster than the connection could carry. Nevertheless, I was captivated by the intimacies I experienced on those early chat boards and discussion forums. Several years later, in 1991 when I began psychoanalytic training, I was already trying to understand how technology could so easily capture hearts and minds. Then what worried me—and what I tried to combat by launching and directing The Psychoanalytic Connection (first as and then, from 1995 until we closed in 2009, where, among other things, we developed and hosted the JAPA Netcast)—was how my new psychoanalytic colleagues were avoiding technology’s significant promise.

Now, decades later, after many years of the psychoanalytic community using PEPWEB, engaging in or following at times fiery listserv interactions, participating in pandemic-specific experiences of online conferences, and providing teletherapies, tech avoidance has become untenable. A role for screen relations in helping us help people solve problems in living is no longer in doubt. However, a complementary awareness of technology’s perils, problems, and inevitable losses is very much in doubt. It seems the nuanced both- and attitude I believe we need is being occluded by familiarity and wonderment. We are reaching a point— organizationally, professionally, and culturally—where an appreciation for the unique value of in-person relating is at risk. At the base of my worry is my observation that many people are acting and talking as if screens and speakers can seamlessly substitute for physical co-presence.

It doesn’t have to be this way, at least for psychoanalysis. From the start of 2020 until the summer of 2021, I had the privilege of working with eight international colleagues on IPA’s Remote Analysis in Training Task Force, ably chaired by Alexander Janssen from the Netherlands. We began with significant differences of opinion, backgrounds, and theoretical frameworks. Despite having to work exclusively online because of the pandemic, we studied and worked together in search of a consensus no one thought we could achieve when we first began. But we did. We found a workable approach to technology-in-training that allowed us to remain true to our foundational beliefs and formative psychoanalytic experiences. We did this by embracing both what technology can do and what it cannot do. Doing so was not easy. Central to our successfully reaching consensus was trusting that appreciating technology’s inevitable limits and losses is not a reason to eschew the technology. Instead, recognizing the inherent problems offered us an opportunity for solutions-focused creativity. Appreciating both promise and peril allowed us to replace the possibility of schisms and splits with an innovative forward-looking approach no one initially thought possible.

Unfortunately, at least at the time of this writing, APsaA seems to be going in a different, more one-sided direction in regard to technology. For example, the absence of both-and nuance is evident in the Institute Requirements and Review Committee’s (IRRC) recently proposed revisions to APsaA’s educational standards. The version that became active early October acknowledged only “the value of distance technology in all components of psychoanalytic education.” There was no balancing acknowledgment that distance technologies also have deficiencies and problems. It failed to direct attention to specific pedagogical skills and institutional requirements considered essential for best practices distance education. The document also failed to acknowledge particular educational need for or benefits from developing skills specific to providing teleanalysis and teletherapy. Though obviously necessary, the proposal reads as though expertise in providing in-person psychoanalytic care is all one needs to provide high-quality teletherapy or teleanalysis. Differences well established by decades of research between what can take place in person and what can take place on screen appear erased by the document.

That the document gives scant credence to the inevitable benefits and costs, rewards and risks is especially prominent in its discussion of candidate teleanalysis. Instead of it being an option that could be made to work when necessary, as we concluded in the IPA Task Force Report, IRRC made teleanalysis a standard option that could be selected solely on the basis of preference. According to the proposed standards, a candidate at an APsaA-affiliated institute could opt for a teleanalysis “to provide a greater choice of analyst.” It reads as though nothing of value would be lost in choosing screens and speakers over physical co-presence. No longer would a candidate need to arrange, despite inconvenience or resistance, to see an analyst in person. With this as the baseline, for example, candidates in Philadelphia could choose analysts in New York simply because they preferred the cachet of that institute. Or a candidate in Chicago, feeling constrained by urban fees, could scour the country for the lowest cost analyst, or the one with the most lenient cancellation policy. In this way, IRRC’s proposed revisions ignore the limitations and inevitable losses of teleanalysis and, correspondingly and likely without an intention to do so, diminished the uniqueness of in-person treatment.

Not everyone agrees. Obviously. But I think this is an avoidable mistake with potentially dire consequences: potential schisms and splits in APsaA; the creation of high and low status graduates; a public image that portrays us degrading in-person intimacies and thereby throwing us into the therapy app basket, along with technopreneurs like Talkspace and Better help that strive for massive profits by being a “disruptive technology” at the expense of vulnerable people seeking help; and, perhaps most important, lost or attenuated opportunities for pedagogic creativity because there is no urgency to solve problems not noticed. I should note that I joined with 13 other colleagues in writing a response to an earlier draft. We requested that IRRC adopt a more nuanced both-and approach. We made specific suggestions for ways of seamlessly including such an approach within the existing structure of the document. None of our substantive suggestions made it into the final draft, further illustrating the document’s expression of a one-sided stance toward the use of technology.

The question, then, I find myself worrying about is why?: Why are so many colleagues moving with such certainty in what the IPA Task Force and I see as the wrong direction? What is it about technology, and our relationships to and through it, that makes it hard to simultaneously appreciate the promise and the peril of distance technology, especially in psychoanalytic education? Based on my work on the IPA Task Force, in numerous workshops taught with Gillian Isaacs Russell, in various study groups, and as co-chair of the APsaA COVID-19 Advisory Team, as well as more than 30 years trying to bring together technology and psychoanalysis, I have noted eight ways technology seduces. Of course, this is not a comprehensive list. Nor does it imply that all points apply to everyone. But I hope sharing my experience here might help bring about the mid-course correction I think so necessary.

…our devices are designed to disappear, to make it seem one really can reach out and touch someone, and to hide the fact that one cannot.

Technology’s Design: Communication technologies are tricksters by design. They are built to create an “illusion of nonmediation,” a.k.a. telepresence. From telegraph operators to the telephone to today’s video conferencing and forward into augmented and virtual reality implementations, these devices work by mimicking the neurotemporal patterning of interactions previously possible only with physical copresence. The richer the temporally appropriate stimulus array, the more powerful the illusion. In this way, our devices are designed to disappear, to make it seem one really can reach out and touch someone, and to hide the fact that one cannot. An experience of “it feels the same so therefore it is the same” is built in. Technologists spend millions of dollars researching deficiencies and problems with telepresence to make the illusion of non-mediation more powerful. It is as understandable as it is unfortunate that so many have become entrapped by telepresence experiences.

Introspective Awareness: Being a psychoanalyst can turbocharge the illusion of nonmediation. We’re trained to access a nuanced awareness of introspective data. When this is combined with technology’s design, it can lead to experientially powerful moments of “I feel close therefore we are close.” But as powerful as they are, those moments can block awareness of both how technologically mediated closeness affords a radically different range of relational possibility and how unique psychological processes need to be deployed to make the illusion work.

Confirmation Bias: Being a psychoanalyst brings awareness but does not inoculate us against the profound influence of unconscious processes, be it from the dynamic unconscious or the cognitive unconscious. We all look for information to confirm what we believe and what we want to believe. For example, someone who wants to believe in technology’s promise for distance training without loss or limitation can look at a survey and say it shows people trained online are better prepared to provide teletherapy. And someone who believes in a nuanced appreciation of promise and peril can look at the same data and conclude people trained online are less prepared to provide in-person care. Confirmation bias supports polarization and our unfortunate history of talking past each other.

Rhetorical Excess: Further contributing to polarization and loss of nuance are the strident rhetorical excesses of those trying to make a point. I have heard proponents of teletherapy and teleanalysis talk with an evangelical techno-enthusiasm reminiscent of the late 1990s when AOL disks rained down like manna from heaven and technologists promised a problem-free techno-utopia. I too have participated, perhaps more than most, trying to deploy the full power of language to first force awareness of technology’s rewards and then lately its risks. The results have been unfortunate. Instead of creative dialogues like that which took place in the IPA Task Force, the dialogue often resembles an old Miller Lite commercial. But instead of shouting “tastes great” or “less filling,” evangelists square off against the neo-Luddites: “functions the same,” one shouts, only to be met with, “differences matter.” I regret those moments when I sunk down into these depths of rhetorical excess.

Cognitive Dissonance and Procedural Knowledge: Social psychologists have long documented how attitudes follow behavior; that which we’ve done tends to become behavior about which we hold increasingly positive attitudes. The unambiguously positive development as more psychoanalysts acquire the procedural knowledge necessary to get things done in the technologically mediated world inevitably carries with it a change in attitude. The more we do online, the more positively inclined we become toward doing things online. Because the pandemic required us all to become overnight telehealth providers, and many of us worked to help others develop the procedural knowledge needed to make that transition, there has been a corresponding tectonic shift in attitudes. I don’t think IRRC’s revisions would be so unilaterally positive were it not for the way cognitive dissonance changed attitudes during the pandemic.

Psychoanalytic Insularity: Since 1953 when Lawrence Kubie stormed out of the Macy Conferences on Cybernetics, psychoanalysis has mostly ignored a vast literature on the psychological consequences and experiences of technology use. Rather than participating in an ongoing conversation with information and computer science, media studies, cybernetics, and human-computer interface studies, we put ourselves in an intellectual silo. Recent discussions on the APsaA Members’ listserv underscore this insularity. It’s as though knowledge and research do not exist unless they were developed within the psychoanalytic literature. As a consequence, little attention is paid to the research documenting the problems and perils of screen relations. Avoiding available research apparently helped make possible IRRC’s disregard of the costs when considering the value of distance technologies.

Present Shock: We’re not immune to culture. The disorienting, onrushing information overload that the American futurist Alvin Toffler warned about in his 1970 international bestseller Future Shock is here, so argues Douglas Rushkoff in his 2013 book Present Shock: When Everything Happens Now. In a state of “present shock” our very perception of time has been altered by things like our “always on always on us” digital devices. Our cultural center has shifted from linear narratives and long-term consequence to the immediacy of experience in the present moment. Once again, there is support for the “it felt the same, therefore it is the same” feeling that undermines awareness that so much is actually different and possibly lost. Plus, there is the uncomfortable reality that we are still mid-pandemic with no real sense of how or when it will end and little appreciation for the traumas we will all need to process and integrate. Surely, at least to my mind, this particular now is not the right time to make unconstrained and uncritical distance education standard policy since we remain in the trauma with no real sense of how disruptive it will prove to be in the years ahead.

Organizational Politics and Financial Pressures: The current state of our organization provides numerous pressure points in conflict with a nuanced both-and approach. Stated generally, most baldly, and in economic terms, APsaA has excess inventory of expertise. Teleanalysis shimmers as a solution by promising increased demand. In addition, unconstrained technology use promises a reputational shift for psychoanalysis from being a moribund 20th-century holdover to being a vibrant 21st-century practice. But, unfortunately, in many ways, that is an empty promise. Current cutting-edge scholarship is much more involved in understanding technology’s risk and reward, in documenting loss. In contrast, the attitudes inscribed in the IRRC revisions actually reflect late 20th-century thinking. I fear they will only confirm the reputation we want to change. While there’s much more to say, there are also specific features of APsaA’s current organizational politics deserving attention. For example, making teleanalysis an option based on candidate choice alone, where candidates will not be limited to those analysts they can see in person, when possible to do so, will likely undermine the ability of some institutes, especially smaller ones, to attract candidates—and therefore their viability.

I want to close, so I can go back to worrying, with a summary statement from the IPA Task Force report that encapsulates one version, and it happens also to be mine, of what a both-and approach looks like:

In summary: Our final recommendations have two foundations. The first is that teleanalysis is similar enough for it to be part of the minimum conditions necessary to graduate competent analysts. The second is that teleanalysis is different enough from in-person analysis to limit its use and to require additional training experiences to compensate for these differences. APSAA

Todd Essig, Ph.D., is Faculty, Training, and Supervising Analyst at the William Alanson White Institute. Since March 2020, he has been co-Chair of APsaA’s COVID-19 Response Team.