We live in a highly mobile, rapidly changing world. Whether we are ready or not, advances in telecommunications, travel, and biotechnology are changing the way we communicate, the way we learn, the way we are born, the way we live, and the way we die. The assumption underlying much of contemporary psychoanalytic theory is that there exists a continuous interplay between the subjective lives of both the analyst and the patient. Equally fundamental, however (though often not explicitly stated), is the notion that each participant exists within a larger social context which itself exerts a continuous influence, though often a silent and indirect one.
As analysts and as people, we eventually accommodate to changes in our society. We do so when the society as a whole has absorbed technological advances or when our patients' and our own needs challenge us to rethink familiar understandings. As analysts we are by nature uncomfortable with change, partially because we understand something fundamental: that even small changes in the way we communicate with each other and the way we live may have profound meaning.
Technology has and will enter our consulting room. It creates an opportunity for us to rethink at times our technique and familiar concepts.
Mr. B, an elderly and anxious man, is embarrassed but finally tells me that for more than a year, several times in the evening and on the weekends he telephones my voicemail just to hear my voice. Knowing that I still exist, he says, settles him down.
Take something as ubiquitous as the answering machine or voicemail. Part of our everyday culture, it has within the last decade become an important part of our clinical practice. It serves a number of analytic functions. It has rapidly replaced the answering service, because it maintains the intimacy and the privacy of the analytic dyad.
Patients may use the answering machine as a transitional object. They may call in between sessions to soothe themselves, to hear our voice, to see if we still exist. In a small way, the use of this technology helps create the illusion in a few of our patients that they have some control over the amount of contact with us.
Annie leaves a message on my voicemail. She was referred to me by Dr. X and wants to make an appointment as soon as possible. She tells me she is in crisis. I return her call immediately. We set up an appointment for the next day. Annie arrives, and she shares with me a powerful
Sharon Zalusky, Ph.D., is a member of the Southern California Psychoanalytic Society. She has published and presented articles on the effects of cultural change on psychoanalysis and on patients, including papers on telephone analysis and infertility treatment.
transference dream that she had that evening, before we ever laid eyes on each other.
Our answering machine is important also because it is often our first introduction to or patients and theirs to us. Before we ever meet, and before we may ever speak directly to each other, we hear the tone and the quality of the other's disembodied voice. We wait to see how easy it is to make the personal voice-to-voice contact, wondering what that says about the other's availability to engage in a therapeutic relationship. Conscious and unconscious fantasies about the other are evoked. We rely upon it, and it has been incorporated into our practice.
Rich, an aspiring actor, lands a major role that shoots outside the country. He must leave in two days, but he wants to continue his analysis while gone. He believes it will help him stay grounded during this great opportunity.
The uses of the telephone and other means of telecommunication are inherently complex. Analysts rightfully have complicated attitudes about using the telephone in clinical practice. Telephone sessions and even a telephone analysis almost always represents a therapeutic compromise, and thus is often conflictual. However, telephone sessions and even a telephone analysis may be a valuable adjunct when one treats patients who for reasons of business, illness, education, pregnancy, family issues, etc., find themselves unable to come to sessions in person.
Freud himself first introduced the metaphor of the telephone to psychoanalysis (in his 1912 “Recommendations to Physicians Practicing Psycho-Analysis”). He recommended that the analyst “must adjust himself to the patient as a telephone receiver is adjusted to the transmitting microphone” in order to use one's “own unconscious like a receptive organ towards the transmitting unconscious of the patient.” If the use of the couch serves, as Freud suggested, to induce a regression in which the analyst as a person does not interfere with the development of the transference, then the telephone amplifies that experience. It minimizes the more pronounced realistic aspects of the analyst.
After years of failed fertility treatments, Diana is pregnant with a donor egg. Her doctor insists that she must stay in bed for the rest of the pregnancy. Its impact on her analysis is yet to be determined. We consider the pros and cons of continuing the analysis on the telephone.
I think analysts are uncomfortable with the telephone, not because it has the potential to dilute the transference, but just the opposite: It has the potential of increasing unconscious-to-unconscious communication. The transference may be intensified, but it is more easily hidden. We have no visual clues to rely upon. Working analytically on the telephone poses unique challenges to the analytic process. We must readjust our technique to help us compensate for the lack of visual input.
What is most interesting theoretically about work on the telephone is that in various ways it focuses, condenses, and makes concrete such basic analytic issues as separation, loss, availability, object constancy, the needs of both patient and analyst, and the analytic frame and deviations from it.
Susie, now twenty-two and away at college in Sydney, Australia, is a woman I first started treating when she was fourteen and afraid to go to camp. Each move forward into adulthood has stimulated intense inner conflict. Recently, out of the blue, I turn on my computer to find an e-mail from her. Susie writes that she loves going to school abroad but finds herself fantasizing about one of her female friends. She doesn't know what to make of it. She finds it both exciting and terrifying.
With e-mail, you take away not only the visual but also the auditory realm of the interaction. Each participant is left to surmise the affect connected to the text. Because of this, the projective aspect of the communication is increased even more than with the telephone. The material often becomes deeper, closer to primary process. E-mail can feel more intimate, more personal, more invasive, more seductive, more distant, more of everything.
Technology is forcing us to accommodate to its presence. It is increasingly becoming part of all our practices. Often it stimulates anxiety because it crosses many of our familiar boundaries. Technology almost always implies a movement from fantasy to action. What was once possible only in the realm of omnipotent fantasy now has the capacity of becoming real. It stretches our notion of intimacy.
As analysts we have a choice. We can passively accept the presence of technology, or we can take the opportunity to study its impact on the analytic process and find ways to adjust our technique.