“Phoney” Therapy?

“Phone therapy is phoney therapy”

A very experienced and adept psychoanalyst made this acid remark, quoted approvingly to me by a psychiatrist who holds him in the highest esteem.

More than a decade ago, I had a patient who had had a very hard time both in
life and in therapy. I was by no means her first therapist. I practice in Baltimore and she was offered a plum job out west. She wanted to take it. One of the major areas of work in our therapy was to help her see just how talented she was and to stop apologizing for it and colluding with the theft of her ideas by co-workers.

While she he wanted to take the job, which represented real recognition for her and a real and useful boost in income, she did not want to stop her therapy, feeling that at last she had found something like an emotional home. She proposed that we continue once or twice each week on the telephone. She said she would fly back to the east coast from time to time to see me.

I dithered. It was not something I had done before. Previously the therapy I had done had involved both participants breathing the same air alone together in the same room at the same time. I told her that I needed time to think about it.

Why couldn’t she find a competent therapist where she was going? Probably she could, but she and that therapist would not share the years of accumulated context that she and I had together. She was very interested in this job and the recognition that she felt it represented but also more anxious about it even than she was aware. If there were an emergent situation there, how would I handle it? I reminded myself that there were emergency rooms where she was going. I also reminded myself that she was an exceedingly responsible and considerate person.

After taking a week to think it over, I told her that I was willing to try it, but that we both would have to watch carefully to see if it was working. I said I had never done it before and that it made me a bit anxious, but that I thought we might well be able to make it work.

So we set out on this voyage of exploration, one made possible by a technological marvel we have come to take very much for granted. It went well. The issues we wrestled with were familiar ones, vividly present in a new geographical setting for the patient.

A remarkable development took place after roughly two months of weekly and occasionally bi-weekly sessions. At the end of the session, she would close by saying, “See you next time.” There was no irony in this at all, no mark of awareness
that precisely what was distinctive about this therapy was that, in the pre-Skype we could not “see”each other as we had been accustomed to do. She said this each time at the end of the session and each time I was just a bit taken aback. I believe what she was implying was that this shared phone presence was quite genuine for her and met her criteria for “being with.”

Therapy on the phone helped her hold her own as she realized that the job she had taken was booby trapped, that it had not been presented to her in a way that was at all transparent, that it presented her with choices that put her principles under stress. While doing a good job, she became aware not only that she had been sold a bill of goods but that she had participated actively in selling herself this bill of goods.
This was in accord with the militant hopefulness that was her lifelong defense against despair.

After a few years, she resigned her position and returned to the east coast, both richer and poorer, richer in financial terms, but poorer in that she was more disillusioned.

I have since treated by phone a former patient who returned in a crisis to therapy from the other side of the international dateline. I have also treated by phone an artist whose life has involved a good bit of dislocation. In both these cases phone therapy rested on the foundation of years of previous tradititional shared physical presence therapy.

Geerat Vermeij is one of the world’s leading authorities on shells. He has been blind
since the age of three. He scans the shells that he studies with his hands and not infrequently notices important structural details that the sighted have missed. So we can say that he “sees” with his hands, nor would we be justified in impugning his particular form of vision.

Much of “seeing” is central in the brain and has to do with complicated processing of the data stream that has been brought in along a specific sensory channel. We know that in blind persons many of the neural populations that process input from the eyes in the sighted can be switched to process touch or sound inputs with a sophistication that is rare because unnecessary in the sighted.

“I see what you mean”

This is not a statement about information brought in through the channel of the eyes. It is about a much more central event, usually a leap from words to meaning.

So what makes psychotherapy genuine or authentic and what disqualifies it as
phoney? The quality of the relationship, whether there is a back and forth, whether
the participants can feel together and explore what they feel , whether there is room for spontaneity – all seems to me to be more fundamental than whether it is air that carries sound, or wires, or electromagnetic waves in a cell phone system.

I have more doubt about manualized therapies that attempt to prescribe what a therapist shall say and how the therapist shall say it. These try to standardize treatment so that a process becomes a procedure. I suspect that monkey wrenches will fly at these therapies both from the side of the patient and from the side of the therapist.

Therapy is now being done over distance by skype, so that there is visual input as well as voice contact. It has even gotten a name, “teletherapy”. I imagine therapy could be done by computer chat like Gchat. I can even imagine it being done by twitter, if that were to be the channel available.

The crucial element in the framing of a genuine therapy is the intent of the parties, their commitment to communicate with feeling about feeling, to explore what hurts and what might help with the hurt.

I still see the vast majority of my patients in the same lovely office with an old cherry tree beside it that I have been using for more than twenty years. I relish their physical presence and what I glean from that.

But I think we underestimate the suppleness and resilience and basic strength of psychotherapy if we insist on a particular set-up as the only legitimate one.

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