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


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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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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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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of the technique of traditional therapy, at times virtually a ritualized one, in which the link between theory and technique could be lost. I want to make clear that I am not criticizing the actual practice of some colleagues; I am criticizing only a possible way of conceiving theory of technique. In fact, a stereotyped understanding of technique would seem to inevitably lead to errors in the conduct also of offline therapy.2

This, then, is the source of my interest in Internet therapy. In particular, it was during an animated discussion I had in 1998 in a forum by e-mail with the editorial board of an online professional journal with which I was involved at the time that I was struck by the difficulty some colleagues had in fashioning a thoughtful approach to this issue. It was then that I realized that the problem lay not in developing a theory of online therapy per se, but in a failure to clarify the underlying understanding of the theory of technique itself. That is, the difficulty these colleagues experienced would have arisen in facing any situation that deviated from “normal” therapy; it was as if the technique of normal therapy had been learned as a ritualized procedure without consideration of the underlying implications.

There is not a separate theoretical arena for Internet therapy any more than there is a separate arena for those therapies practiced in other kinds of “heterodox” situations. In recent decades, new frontiers and the “widening scope” (L. Stone, 1954, p. 567) of psychoanalytic intervention have tested the inner consistency of the so-called “basic model of psychoanalytic technique” (Eissler, 1953, p. 108), or “classical technique” as it historically developed. This testing of our technique is still encountered in daily, routine work, whenever the patient—labeled for example as “borderline”—succeeds in challeng- ing or confusing an analyst armed with the best intentions. Some mistaken ways of conceiving therapeutic work may never come to light if the analyst relies on traditional clinical practice and has an untaxing patient population. But they immediately become evident as soon as the analyst has to face a new situation with a different type of patient. I believe these problems derive from the way theory of technique was transmitted in some psychoanalytic circles in the past, and at times we may still see its remnants today.

More than 60 years ago Leon Saul (1951), the first analyst I know of to ponder the use of the telephone in psychoanalysis, addressed the underlying point in The Psychoanalytic Quarterly:

All thinking is restricted by inertia. We think as we were taught to think. New ideas, attitudes, and approaches always encounter resistance. This is especially true in psychoanalysis, where because the personal analysis mobilizes the unconscious submissiveness to the parents, and the narcissistic identification with them, the teacher’s authority tends to be unusually great, and carries with it special obligation to impart a truly academic and scientific outlook. This is an ironic quirk in a science born of one man’s devotion to reality despite the weight of all sorts of authority. In view of these considerations, one wonders if the idea of using modern technology in the form of the telephone, as an adjunct to psychoanalytic technique, will be met with horrified resistance, or whether most analysts are already far ahead of this in their thinking and anticipate experimenting with televisual communication if and when this becomes practicable (Saul, 1951, p. 287).

2 In another paper (Migone, 2009), I have utilized the same approach to so called “brief therapy,” which provides the opportunity for reflecting on wider problems pertaining to both “brief” and “long-term” therapy and to the theory of technique of psychotherapy in general.

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These words sound prophetic. Prophetic, too, was Saul’s summary judgment: “Every technical procedure is only a means to an end, and its use must depend upon the basis of the rationale of all treatment: psychoanalytic accuracy in understanding the patient” (p. 290). In the paper Saul discussed, among other things, the usefulness of using the phone with a patient who at the moment was unable to handle her emotions during sessions. However, he realized that over the phone—for reasons too complicated to discuss here—she was able to talk about specific transferential issues, making possible their working through and the subsequent resumption of regular sessions. The use of telephone, in this case, perfectly satisfied the criteria that 2 years later Kurt Eissler (1953) introduced as a way of systematizing in a coherent way the introduction of modifications of “basic model technique” which he called parameters.

And it is with Eissler’s conceptualization that I want to anchor my reflections on Internet therapy. I am well aware that Eissler’s (1953) conceptualization of “parameters of technique” is generally considered outdated in contemporary psychoanalysis, but—as I will try to show in this paper—I am convinced that it is often misunderstood, and it should remain an unavoidable point of reference within the debate on theory of technique. It is generally recognized that today theory of technique is more a subject of debate rather than of consensus, but in order to have a debate we need to have positions to be confronted with each other, and my paper represents just one of these positions.

Could Internet Be Considered a “Parameter” of Technique?

I am obliged to begin by noting at the outset that Eissler himself was against the idea of an online psychoanalysis, at least as it could be conceived of 30 years ago. At a meeting held at Cornell Medical Center in New York on the occasion of the 30th anniversary of his classic 1953 paper on parameter, I heard him say that one might argue that maybe there was some truth in the criticisms some had leveled against his concept of parameter, to the extent that nobody ever succeeded in conducting an analysis with the computer or by passing over to the patient interpretations written on pieces of paper. The implication, perhaps, was that there were limits to how austere an analysis could be. What this implies for the current discussion I will take up shortly.

First, we need to spend a few words on that classic paper itself, since, as I said, I am convinced that it is often misunderstood. I will try to show that Eissler’s concept of parameter cannot be easily dismissed, because it still has important implications for the identity of psychoanalysis. As is well known, Eissler’s 1953 paper was written in the mid 20th century in an historical period marked by a great expansion of psychoanalysis within the U.S. as more and more patients sought psychoanalytic treatment, including some with diagnoses indicative of severe psychopathology. Very soon analysts realized that classic technique could not be applied to all such patients, and that modifications were necessary depending on the severity of the diagnostic condition. Classical technique, in fact, was based on a privileged use of verbal interpretation, with the virtual elimination of all other “spurious” factors such as reassurances, advice, variations of length and number of weekly sessions, and so forth. The analyst was supposed to stay as neutral as possible, to remain a blank screen, sitting behind the couch in order to minimize his influence on the patient, and limiting himself to verbal interpretations that were conceived as psychoanalysis’ mutative factor par excellence. It is in this context that Eissler’s paper has to be understood.

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In his paper, Eissler systematized the problem of pragmatically indispensable modi- fications of technique in the light of the theoretical implications of ego psychology (at the time the dominant theory in North American psychoanalysis); that is, of the felt need of taking into greater consideration the points of view of adaptation and defense. He called a “parameter” any change in basic model technique (which was defined with “zero” parameters), and suggested that a technique could be still called psychoanalysis if the introduction of a parameter was based on the following four criteria: 1) it should be introduced only when there is evidence that the standard technique is not sufficient (that is, when there is an ego deficit that does not allow the patient to tolerate basic model technique); 2) it should never go beyond an inevitable minimum; 3) it should be eliminated before the end of analysis; 4) its repercussions on the transference should never be so great that they cannot be worked through and eliminated with interpretation (see Migone, 2010, pp. 69–70).

Thus Eissler reasserted the value of basic model technique, which can never be reached in reality, as he was well aware, but remains useful as an heuristic goal, while accepting the use of parameters on the conditions that they could be reduced to a minimum and worked through with interpretation (which would be evidence of structural change and thus indicative of the repair of the ego deficit that had required the parameter’s introduction in the first place). In other words, this conception of psychoanalysis relies on the role of interpretation, which is strictly linked to a specific ego structure, while it is well known that contemporary psychoanalysis relies on a much wider conception of treatment seen as a wide ranging and diversified set of interventions. Behind this statement, of course, there are important and often debated issues concerning the identity of psycho- analysis itself.3 In fact, one might arguably say that some “psychoanalytic” theories or techniques—especially today—are identical to some “psychotherapeutic” theories or techniques. However, many discussions on the identity of psychoanalysis (and especially of the “psychoanalysts”) often confuse theoretical with political issues; that is, the need to clarify our position and to discuss them in depth should not be inhibited by the (often fantasized) threat of exclusion from the psychoanalytic movement (to this regard, see Migone, 2011).

We all know that psychoanalysis today is practiced in a very different way from the classical, mid-20th-century technique, but curiously this “new” technique can be ex- plained in different ways according to which theory we use. For example, Eissler himself, who is still considered by many as the champion of old fashioned classical technique, was extremely flexible with his patients, to the point that his technique to some extent could resemble a form of “contemporary” psychoanalysis. A recent article by Emanuel Garcia (2009), Eissler’s literary executor, describes in detail his technique, and it is impressive to see how Eissler was flexible, free, and able to intervene according to his patients’ needs while simultaneously maintaining a psychoanalytic stance (one might argue that the same could be said of Freud’s technique, with the important difference that they had another rationale: Freud was trying to do everything he could in order to recover memories of traumatic events, while Eissler was trying to do everything he could also in order to respect the patients’ defenses). What I mean is that there is nothing wrong in having a

3 As a recent example of such debates, see the four critical Letters to the Editor (by Lewis Aron, 2010; Yoram Hazan, 2010; Emanuel Berman, 2010; and Steven Stern, 2010), stirred by Rachel Blass’ (2010a) paper titled “Affirming ‘That’s not psycho-analysis!’: On the value of the politically incorrect act of attempting to define the limits of our field” (see also Blass’ [2010b] reply and my comment [Migone, 2011]).

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flexible technique and improving our therapeutic potential, but the theoretical problem remains: how do we differentiate psychoanalysis from psychoanalytic psychotherapy (this in fact was the main goal of Eissler’s paper) or from one of the many types of experiential therapies? (i.e., based on corrective experiences, without an attempt at uncovering un- conscious content or clarifying meanings). I think that Eissler tried to give a reply to this question; that is, he defined on the conceptual level what could be properly called psychoanalysis. As I said, this is often perceived as a hot issue because many colleagues fear that these theoretical discussions imply a threat of exclusion from the psychoanalytic movement. But this is a big misunderstanding of the relationship between theory and technique. In fact an implication of a correct understanding of this discussion is that—in Eissler’s terms—in order to perform a correct psychoanalytic technique one has to be flexible (i.e., perform what could be defined a “psychotherapy” from the descriptive point of view), otherwise he would not be a psychoanalyst (a strict adherence to a psychoan- alytic technique with a patient who cannot tolerate it would be a technical error). And even if, for the entire course of the treatment, it would be impossible to eliminate—in Eissler’s terminology—the parameters before the end of analysis (i.e., even if it would remain a “psychotherapy”), still the therapist would be employing psychoanalytic technique and theory (i.e., he would remain a “psychoanalyst”).

It is becoming more clear now why I am pivoting these reflections on Internet psychoanalysis on Eissler’s concept of parameter. But there are other reasons why Eissler’s concept of parameter is interesting in this regard: Ironically, and contrary to the skepticism of many analysts toward therapy over the Internet, it would seem that an online psychoanalysis, based only on the “impersonal” communication between therapist and patient, could satisfy the comparatively austere criteria for classical psychoanalysis, seen by many as “deeper” and more therapeutic than other therapies! For on the Internet the mutative ingredient, verbal interpretation, remains in place. Nor are other aspects of the classical treatment set-up altered (neutrality, a blank screen, analyst out of sight, etc.). Actually, in all these respects, we could say that e-mail therapy mimics classical psycho- analysis.

How are we to understand this surprising resemblance? A full discussion would entail a detailed evaluation of the history of theory of psychoanalytic technique over the last century. Here I can make only brief comments (for further discussion, see Migone, 1991, 1994a, 1995, 1998a, 2000, 2001, 2003, 2010 chapters 1 and 4). To begin with, the current cautiousness about endorsing Internet therapy can perhaps partly be explained by refer- ence to the fact that recent decades have witnessed growing criticism within the psycho- analytic movement, amounting to almost a complete rejection, of the conceptions of the classical model insofar as they were based on the therapist’s anonymity. That is based on what I once called, borrowing a medical metaphor, the analyst’s “personectomy” (Migone, 1994b, p. 130; 2004, p. 151). As Kernberg (2011), among others, has argued, this development is possibly due to the fact that often “anonymity” has been confused with “neutrality,” and it could also be “a product . . . of the authoritarian structure of psycho- analytic ego psychological and Kleinian institutions in the 1940s and 1950s” (p. 656). It is precisely that personectomized model that would seem to be exemplified in an extreme form, indeed to the point of caricature, by Internet therapy. Yet herein also lies an opportunity: The diffusion of Internet therapy, among other things, by reopening this problem within the debate on psychoanalytic technique, gives us the opportunity to reexamine these issues of theory of technique.

Following Eissler’s argument, a therapy with parameters (i.e., modifications of the rules according to the patient’s needs, with interventions by the therapist who in a complex

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way modulates the classical model technique) is indicated for those patients who, due to their ego deficits, are unable to tolerate a model of technique based only on interpretations. Should we deduce, then, that Internet therapy, with its reliance on verbal interpretation, is indicated for those patients who have an intact ego (who, by the way, are extremely rare) or that have milder forms of psychopathology? I think this is not the way to set the problem, the issue being more complicated. But please note, however, the apparent paradox: On the face of things, Internet therapy would seem to be indicated for healthier patients, who could benefit from a restricted diet of verbal interpretations alone. Then again, for different reasons, it would also seem indicated for sicker patients; that is, those who are afraid of emotional closeness or overinvolvement with the therapist (such as Saul’s [1951] patient mentioned earlier who used the telephone for a period of time).

Incidentally, in this context it is not compelling to argue that today, thanks to the possibilities offered by the multimedia communication, “virtual” therapy does not need separate justification given the extent to which it can simulate “real” therapy. I do not recall the further details of Eissler’s discussion in his talk as to the possibilities of psychoanalysis with the computer, but I think that if skepticism toward Internet therapy was once understandable, technological advances do not of themselves provide sufficient reason to be less skeptical and to think that Internet therapy can be indicated for either healthier or sicker patients. But in any event this is not the way, in my opinion, that we should be thinking about the problem. The issue is not whether it is possible or not to simulate with “virtual” reality (today possible over the Internet) the “real” reality of the patient�therapist interaction, with the latter being held up as a model or an ideal which we should try to approximate as closely as we can. The problem needs to be stated differently; namely, by reflecting on the theoretical premises inherent in Eissler’s con- ceptualization of “classic” technique, the very premises that have themselves lately been viewed critically in many psychoanalytic circles.

Eissler’s reasoning had a high degree of inner coherence, and his 1953 paper is still valid regarding the role of the analytic frame in the logical structure of psychoanalytic interpretation (in this regard, see Codignola’s [1977] important contribution on—I quote his book’s subtitle—the “logical structure of psychoanalytic interpretation”). In his paper Eissler wanted to deal with the important issue of the relationship between words and action in analysis, and the role of mentalization, as we might now call it, as a guarantee of the patient’s autonomy from the environment; that is, from the parameter that was introduced in order to help him reestablish his psychological equilibrium. On such an opportunity hangs the possibility of psychoanalytic change, that is, structural change. In fact, a parameter (such as a reassurance, an action, or a corrective experience) is introduced just because interpretation does not work, and it takes the place of interpre- tation, so to speak. In Eissler’s words, it is necessary because of an “ego deficit” (e.g., the inability to understand the meaning of a symptom), so that only a behavior (the parameter) and not words (interpretation) can help the patient. When the patient is able to use interpretation (i.e., to mentalize), the parameter can be eliminated and it is possible to go back to the “basic model technique.” Incidentally, it must be clear that, according to this line of argument, if Internet can be a “parameter” of technique, the reverse could also be true; namely that non-Internet therapy can be a parameter of Internet therapy if the latter is the treatment set for a given patient. For example, an Internet therapy patient might temporarily need to be reassured with one or more vis-à-vis sessions if he is going through specific difficulties that, for various reasons, cannot be worked through within the online setting, so that the analyst decides to introduce a parameter that in this case consists of

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traditional, offline therapy.4 This possibility may appear paradoxical, but is totally coher- ent with the concept of parameter if one is able to understand what Eissler was trying to say regarding theory of technique and the logical structure of interpretation (see, to this regard, Codignola, 1977).

The aspect of Eissler’s conceptualization that more directly concerns us here, how- ever, and that has come to be seen in a very different light in recent years, involves what he called “basic model technique.” Embedded in his description of basic model technique was the idea that only one kind of technique, the classic one, in which the analyst sat out of sight and was careful not to intrude his own personality in any way, is good for evoking the transference. Tightly linked to this premise was the further notion that this kind of model, with the analyst endeavoring to provide only a “blank screen,” guarantees a “pure and uncontaminated” transference, and a truly free association; that is, uncontaminated by the analyst’s influence. As argued in later years by several authors (in primis Gill [1982, 1983, 1984, 1994], who in his own way reevaluated and reinstituted the intuitions of Sullivan and other interpersonalist authors dating back to the 1920s and 1930s), this faith in the analyst’s effective nonbeing could be highly naïve. Indeed, this faith can lead to the analyst’s having an increased influence on the patient precisely because it is not analyzed (in fact it is not considered to exist; see Migone, 2000; Green, Kernberg, & Migone, 2009, pp. 219–221).

Here let us examine for a moment—and only as one of the many examples of a way of reasoning around the meaning of a given psychoanalytic frame—Gill’s critique of Macalpine’s (1950) earlier conception of psychoanalysis as an “infantile setting.” Ma- calpine had argued that, as an “infantile setting,” classical analysis would be apt to evoke just that kind of transference which we want to analyze. She defined the “infantile setting” in terms of the regular frequency of sessions, the use of the couch, a stable, unchanging environment, and so forth; that is, the very model of technique that Eissler would subsequently talk about in his paper. But Gill (1984, pp. 169–170) pointed out a contradiction in this regard: If transference is conceived as spontaneous and “uncontam- inated” by the present situation, why then would we need specific measures (such as the couch, a stable, unchanging environment, etc.) in order to provoke it? In other words, why would we need to “manipulate” it by providing an “infantile setting”? The transference that now appears would not be a repetition of the past enacted in front of an analyst who remained a blank screen, but simply a more or less expectable reaction to that “infantile setting.” It would be an “infantile transference,” or, alternatively, a “classic transference” evoked by a “classic frame,” only in the sense of an iatrogenic reaction conceptually similar to hypnosis, which is the contrary of psychoanalysis. Very beautiful are the pages in Gill’s critique in which—pace the orthodox analytic view—he shows how a classical analysis could in effect be a “manipulatory psychotherapy,” while a once-a-week and vis-à-vis therapy in which the transference is carefully analyzed could be a “psychoanal- ysis” in every respect.

Obviously, or perhaps not so obviously, Gill’s demolition is not meant to be a critique of the ground rules of classical psychoanalysis—which are rules like any other, neither better nor worse—but a critique of the idea that any given frame, any given set of rules,

4 In a similar vein, elsewhere (Migone, 2000) I described the clinical case of a patient who, during a vis-à-vis therapy, had to lay on the couch for a few sessions in order to overcome specific transferential difficulties originated by the vis-à-vis setting. That intervention was conceptualized and worked through as a typical parameter in Eissler’s (1953) sense; the seemingly paradoxical title of that paper was “A psychoanalysis on the chair and a psychotherapy on the couch.”

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guarantees the analyst’s lack of influence on the transference, and that only those rules should be used for every patient in all cultures and historical periods. In point of fact, the latter stipulation is indeed the underlying implication of how psychoanalysis exists institutionally, otherwise we would not have the International Psychoanalytic Association setting standards such as the use of the couch and a schedule of four times a week as the desired frequency (even if we all know that these rules are followed more in theory than in practice, and that changes in these rules are under way).

The inability of the “classic” rules to guarantee an uncontaminated transference across the board necessitates an alteration in how we understand the analysis of transference. This is why—according to Gill—the classical rules are not justified any more, so that he proceeds to do away altogether with “extrinsic criteria” (couch, frequency, etc.), while redefining “intrinsic criteria” (he centers them only on the analysis of transference) and espousing a radical and enlarged definition of psychoanalysis which is applicable in the most diverse settings, including once-a-week therapy or therapy with variable frequency, groups, emergency consultations, brief therapies, treatment of patients with more severe diagnoses and/or on medication. What is important is that the analyst always does his best to analyze the transference. This is the only intrinsic criterion Gill saved, and it could perhaps better be defined as “analysis of the relationship,” since Gill conceived it in a “relativistic” or “perspectival” way, that is as an analysis of the patient�therapist interaction, which is always influenced by the setting, whatever it is.

Thus, it would be a mistake to argue that the classic model is inferior to another model; for example, without a couch, or with a lower frequency per week, or, for that matter, even over the Internet. The classic model is a model like any other; it will only evoke its own type of “contamination” of the transference. Every patient, in fact, will react to a given setting not according to some ideal model we think is valid for every patient, but in his or her own idiosyncratic way since it is the transference itself, based on the patient’s past experiences, that will determine how the setting will be perceived by the patient. As a very simplistic example, if a patient had quite reserved and silent parents perhaps he will be at ease with an “orthodox” analyst, while a different patient with parents who were very warm and exuberant might perceive this same analyst as cold or detached. It is obvious that it would be wrong to see as transference only the latter’s reaction and consider as “normal” (i.e., nontransferential) the nonconflictual state the first patient is in when he is with a silent and reserved analyst. Indeed his apparently “normal” reaction with an “orthodox” analyst would not allow us to shed light on this important area of the patient’s functioning, which, however, would likely become more visible if he were to be exposed to a different setting with the result that it could then be analyzed (for a discussion of Gill’s ideas, see Migone, 1991, pp. 71, 2000, 2005, 2010, pp. 71–79; Green, Kernberg, & Migone, 2009, pp. 216–221). The allusion to Internet therapy here is obvious, because transference configurations might appear that would never appear in other settings (and this is true, of course, for any setting).

It may be clear at this point why I wanted to pivot my reflections on Internet psychotherapy on a review of Eissler’s concept of parameter together with Gill’s position on intrinsic and extrinsic criteria for defining psychoanalysis. If we accept that there is no longer any “gold standard” for psychoanalysis in terms of extrinsic criteria, it logically follows that we can also conduct an analysis on the Internet (however, as I stated earlier, the aim if my paper is not to show the legitimacy of psychoanalysis on the Internet, which is only an implication of a more general discussion on theory of technique and on the identity of psychoanalysis; in other words, it would be a misunderstanding to conclude, simplistically, that this paper is “in favor of psychoanalysis on the Internet”). What is

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important is the careful analysis of the transference manifestations according to the context in which the patient�therapist interaction occurs, in this instance on the Internet in all its variations. We must simply proceed with the awareness that this context, like any other context, will always have an important influence on the transference and on the countertransference as well.

Further Considerations

In order to avoid possible misunderstandings, some further clarifications are necessary. Specifically, it is important to analyze some of the implications underlying the argument that has been made to the effect we should not exclude Internet therapy a priori. Many colleagues have a summarily critical and even dismissive attitude toward Internet therapy. Such a reaction is understandable if we think of its possible abuses in terms of fostering “wild analysis” or its indiscriminate use as a substitute for traditional therapy. Actually, the logic of why Internet therapy should selectively be abused is not clear, since many therapists might find it more difficult and the format itself is less remunerative. Perhaps it may be abused in this first, pioneering phase as some exploit this new modality to search for patients that cannot so readily be reached and enrolled in treatment in other ways. But soon this territory will be overpopulated and the “first come, first served” rule will no longer apply. In which case qualified practitioners will crowd out less able ones to more or less the same extent they do now. I do think that we should be critical of Internet therapy but only to the extent that we are equally critical of traditional therapy, which is equally prone to being abused and practiced in a “wild” fashion. What I think should be emphasized is that a critical attitude toward Internet therapy on a priori grounds can hide a permissive attitude toward traditional therapy. Moreover, such an a priori rejection may involve the incorrect assumption that the external criteria of psychoanalysis are the determining factors (this issue, of course, has to do with the identity of psychoanalysis). To the contrary, it is the meaning of the whole experience that characterizes therapy (including the interplay between extrinsic and intrinsic criteria).

This gives us the opportunity to reflect on what we mean by “communication” between patient and analyst. Communication refers to the meanings that are transmitted, and this transmission can occur in many different ways, not only in person or during live interactions such as in the traditional psychoanalytic situation. As we well know, at times a half word by telephone (or, for that matter, over the Internet, even with an e-mail or an sms) may have more powerful effects than a detailed communication during a session. The common idea that communication between patient and analyst ideally should occur during a traditional psychoanalytic session might hide a misunderstanding of the relationship between extrinsic and intrinsic criteria of psychoanalysis. In fact, the privileging of extrinsic criteria cannot but lead to technical errors also within traditional, non-Internet psychoanalysis. In this regard, examples are innumerable. Let us think only of the couch: Those who are against the therapeutic use of Internet may be the same (actually, often are the same) who believe that the couch (or any other element of the setting, for that matter) is essential for psychoanalysis, when in itself the couch is irrelevant (what is relevant is the patient’s reaction to the couch, as well as to the chair or to any other aspect of the ground rules; see Migone, 1998a, 2000). This stereotyped reasoning, as Galli (1988, 1990, 2002, 2006) has argued convincingly, brings with it a reification of technique, as if, so to speak, technique could itself become “theory.”

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Internet psychotherapy would appear to be particularly useful not only when there is a great geographical distance between patient and therapist, but also when it is used in ways that are consonant with Eissler’s conceptualization of a parameter. That is, it may be indicated in those cases (typical examples are schizoid personality, agoraphobia, or social phobia) when the patient is unable to face the personal contact with the therapist while he is able to open up at a certain emotional distance that is being symbolized by physical distance (there thus being an “ego deficit” in Eissler’s terms). The patient might well be engaged in an initial phase of treatment in this way if, for example, he initially asks for help on the Internet or by e-mail; then after his resistances are worked through he might be able to continue with traditional psychotherapy if this is the modality deemed appro- priate. Of course, also the opposite could occur; a patient might begin with traditional psychotherapy and later, after all resistances are worked through (both on the part of the patient and of the analyst), he could continue with Internet therapy if this modality is considered appropriate. In any case, a deep and prolonged analysis of all transference and countertransference dynamics is indispensable before such decisions—just like for any other decision, for that matter; for example, regarding the complex problem of the termination of an analysis (or of many other problems that involve complex technical decision and that are typical receptacles of defenses on the part both of the patient and the therapist and of transferential and countertransferential issues, e.g., to name only one, deciding whether to accept the patient’s request of inviting the spouse at a session in order to discuss a specific problem). Especially countertransference should be carefully ana- lyzed, not only because the choice of Internet therapy could stem from defensive reasons on the part of the analyst (e.g., in order to avoid an emotional closeness with the patient that the analyst sees—erroneously, as we have seen in our discussion—as related to vis-à-vis therapy), but also because, conversely, the choice itself of preferring a tradi- tional, “normal,” non-Internet therapy rather than an Internet therapy could be a counter- transferential issue (e.g., in order to avoid specific emotions that the analyst sees—again, erroneously—as related to Internet therapy, or due to his prejudice toward Internet, or to his fantasies about Internet or the new technologies, and so on, in other words to his “transference,” i.e., countertranference in the narrow sense).

Internet therapy can have its own dignity as a technique, exactly in the same way as other techniques have their own dignity, techniques such as group therapy, family therapy and so on. In fact, in these latter cases the question of which technique to choose and why should always remain open (e.g., with a given patient should we recommend individual or couple therapy?). What is important—in a truly psychoanalytic way of thinking—is not so much our final decision, but the fact that the question remains open and that the transference and countertransference dynamics of these preferences are continuously analyzed. In a way, the choice made is less important than our continuous questioning as to why we made this choice and not another one.

The theoretical and technical problems of Internet psychoanalysis are in many ways identical to those of telephone analysis. This technique has now been practiced for decades by many analysts, though for many years it was not so frequently discussed, or at least not so frequently as it should have been, given the fact that it has been so widely used. (Often, telephone calls to patients were described as “incidents” during a “normal” analysis). In recent years, however, discussions of telephone analysis have become more open (see, e.g., Hymer, 1984; Lindon, 1988; Sleek, 1997; Zalusky, 1998; Aronson, 2000; Lipton, 2001; Richards, 2001; Zarem, 2001; Leffert, 2003; Bassen, 2007; etc.), and a panel on telephone analysis was held on August 1, 2009, at the 26th IPA Congress in Chicago,

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chaired by Charles Hanly and Horacio Etchegoyen, with papers by Jill Scharff, David Scharff, Geoff Anderson, and Neville Symington.

Personally, I am convinced that the issue of telephone analysis was previously not so widely discussed as it deserved because its theoretical examination could not have helped but have important repercussions on the whole relationship between theory and technique within “traditional” psychoanalysis. The tacit, unvoiced risk here was that a discussion of telephone analysis would have amplified the momentum of a shift in the field in the direction of the position taken, for example, by the late Gill (1984). The myth of technique characterized by extrinsic criteria remained very reassuring for many analysts, especially at a time when past theoretical certainties seemed to have led to a crisis and any number of alternative theoretical models were appearing in the psychoanalytic marketplace. The theoretical pole having been revealed as fragile, clinging to the technical pole was an understandable inclination for analysts reacting to the threat of what they perceived as a loss of identity (see Migone, 2000, pp. 229–231). (I will not comment here on the wider political and economic implications of the need to have a fixed procedure and setting for the sake of a worldwide professionalization of psychoanalysis; these are easily under- standable and not the subject of this paper.)

Internet psychotherapy could be considered on its own terms as a new frontier, in the same way as in the history of psychoanalysis a “widening scope” (L. Stone, 1954) led many analysts to face new technical problems that had the beneficial effect of forcing a reformulation of theory. Think, for example, of the therapy of psychosis (Sullivan), of children (Melanie Klein), of narcissism (Kohut), of borderline and severe personality disorders (Kernberg and others), and also of adolescents, small and large groups, families, addictions, delinquencies, and so forth. As we know, the exploration of these territories produced a healthy rethinking of the classic theory of technique, one that in turn produced generalized innovations that have enriched our understanding of curative factors.

What is important is not the fact that therapy is conducted with or without the Internet, but the theory we use to justify it, including most especially our ability and commitment to analyze the transferential and countertransferential reasons that lie behind the choice. Has perhaps the patient, or the analyst, in their preference for Internet psychotherapy, enacted a defense against some aspect of traditional therapy? And if this is the case, why? Contrariwise, has the choice for traditional therapy been made by one of the two parties or both as the expression of a resistance to an aspect of Internet psychotherapy that would have been possible or useful to investigate? And so on. These considerations are not specific to Internet therapy; they are the same choices as the ones we make for any intervention or therapeutic modality whether individual, group, family, or couples therapy. These choices, as well as their opposite, can be used as defensive receptacles, and it is the careful analysis of the dynamics involved that constitutes the fulcrum of our work. There is no place where we can rest psychoanalytically (for a more detailed discussion of these problems, see Migone, 1994a, 1995, 2000, 2005, 2009, 2010, chap. 4). What I want to emphasize is that we are not talking only of Internet therapy but of therapy tout court; that is, of investigating the rationale behind any technical choice. It is only by clarifying the theory of technique that is behind our choices that we can avoid being stuck in the blind alleys of Technique with a capital “T” (i.e., a technique without a theory, or that has taken the place of theory), and face, among other things, the technical issues of therapy with or without the Internet.

I would like to make one final comment on the notion that a classic technique as embodied in a particular set-up is apt to evoke the specific transferential or “regressive” reactions that we want to analyze, because here once again there is an interesting parallel

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with Internet psychoanalysis. We often hear that the Internet represents a particularly charged setting for many subjects, more specifically that it evokes intense emotions and regressive or “perverse” states. Think of erotic chat lines, or of the phenomenon of a sudden and intense falling in love on the Internet, or of pedophilia, and so on. It seems that the Internet is able to stir deep or repressed emotions, emotions that may, at times, be paradoxically more intense than those evoked by normal, offline situations. Actually, in my opinion, this may well be true for particular individuals but not for all, and it would be a mistake to generalize these phenomena when they might only apply to a given society or subculture. But let us assume that it is a more or less general phenomenon for the purpose of argument. In that case, an argument could be made that this is precisely what we want to have happen in the analysis, so we could analyze it. What I would like to point out here is that this kind of logic is the same that is utilized in the case of classic psychoanalytic technique, insofar as it is asserted in that connection that a particular set-up (couch, rituals, the analyst as blank screen, Macalpine’s [1950] “infantile setting”) aims at provoking the given behavior—transference—that we want to analyze. According to this reasoning, classical psychoanalysis and Internet psychoanalysis would be to that extent homologous. Indeed, once again, Internet therapy would seem to be a veritable caricature of psychoanalysis with infantile transference being evoked in the latter and perverse activity—with its characteristic transferences—in the former. These reactions would equally be forms of presumed analytic “regression.”

As should be clear at this point, I disagree with this logic. In fact, in both cases the mistake is to generalize to all subjects the effect that a given stimulus has on a particular group of people. Moreover, even if this kind of reaction might in fact be generalizable across different subjects, it is not clear why we would want to evoke this type of transference and not another (see, in this regard, Gill’s [1984, pp. 168–171] lucid critique of the concept of regression in analysis). In other words, why shouldn’t we be just as interested in evoking a transference that is different from the one evoked by classical psychoanalysis—or for that matter by the Internet?

One final point in closing. This paper, as it has been emphasized, does not deal with the differences between online and offline therapy per se, but on the theoretical implica- tions of the way we think about a given therapeutic setting; in other words, it is a paper on theory of psychoanalytic technique. However, a de-emphasis on the differences between online and traditional therapy might overlook the fact that indeed there is a difference, and this difference should be clearly spelled out, but again with a privileged emphasis on the theoretical implication of this difference (and—as we’ll see—on its philosophical implication, in a way): one aspect is undoubtedly absent in Internet therapy but present in traditional therapy—the “physical” body of the patient. This absence can be a fundamental problem for so-called body or movement therapies; that is, therapies that use the patient’s body as such within therapy, and not just the patient’s fantasies and emotions about his or her body. From this point of view, Internet therapy is surely “inferior” to traditional therapy. But, if the considerations I have advanced in this paper are cogent, then we cannot deny that traditional therapy, logically speaking, is itself “inferior” to Internet psychotherapy—or to any other type of nontraditional therapy, for that matter—because it is deprived of important data that can only be evoked with the sole presence of a “virtual” body. “Virtual” reality and “real” reality (assuming that the latter can be understood as such, a philosophically tricky proposition that cannot be discussed here) are not superior one to the other, but simply two different kinds of experience. Each one deserves to be investigated and respected; each one is able to give us precious information on human nature.

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  • PSYCHOANALYSIS ON THE INTERNET
    • Technical Aspects of Internet Communication
    • Why Is Psychoanalysis on the Internet Interesting?
    • Could Internet Be Considered a “Parameter” of Technique?
    • Further Considerations
    • References

The post PSYCHOANALYSIS ON THE INTERNET: A Discussion of its Theoretical Implications for Both Online and Offline Therapeutic Technique appeared first on Infinite Essays.



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