I have worked on the telephone with patients from twenty-five to seventy-five, men and women of diverse backgrounds and dispositions. I have always started with them in the office and then good reasons intervened to make it make sense to go on on the telephone.

This work has spanned states, countries, hemispheres, the complexities of time zones. It is a testimony to how remarkably robust communications infrastructure has become that this has been possible. There are limits, too. I have never tried working with a patient who was acutely or chronically suicidal in this way. I have never tried working with a floridly psychotic patient.

One woman who was on the other side of Mississippi from where I am here in Baltimore
used to end each session by saying quite brightly, “See you next time.” It was some time before it struck me just how remarkable this sign off was because in the usual sense related to the visual apparatus it was precisely seeing each other that we could not do and would not do. But, of course, I think she meant another kind of seeing, one constituted by emotional presence in relationship mediated by inner attachment processes that guide imagination.

So I found myself slowly wondering how presence is constituted. We often speak of it as if it had primarily to do with shared location in space and time. But perhaps it is much more imaginary than that. Yes, it requires some back and forth as a condition,
but many different kinds of back and forth are possible. I realized that I had patients who came to see me in my office who resisted presence, mine and theirs, any linking, any shared imaginary creative process, while some of those I worked with at great distance allowed me to be quite close and let themselves fully participate in processes of joint open interpersonal imagining.

So I have been walking along a peculiar path. I’m not at all sure that the medium is the message. Presence is a puzzle, always with imaginary contributions from both sides. The telephone can serve fundamental mammalian attachment and relationship projects, provided both participants have the capacity for abstraction (and the modulation that it makes possible) to stay in touch without literal touch. Yet actual touch, the kind that involves skin on skin, remains such a vital part of life.

However, it is possible to have skin in the game when the actual skins are separated by hundreds or thousands of miles, not to mention professional boundaries. Psychotherapy is full of mysteries that keep on changing.

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