Teletherapy

Will therapy, especially the psychoanalytic variant, be one of the casualties of the pandemic?

Adam Gopnik does not quite say it, but one may reasonably draw the conclusion from his excellent survey of therapy in the age of Covid-19. Whatever conclusion you draw, Gopnik’s survey of the state of today’s therapy is clear and comprehensive, well worth a read.

Early in his essay Gopnik lights on the most salient point: most therapy is basically theatre. It is about dramatizing problems, not working on them or solving them. It is about learning to tell stories in an entertaining fashion, not resolving difficulties and learning how better to navigate the shoals of everyday life. If you were wondering why so many New Yorkers are Drama Queens here is the answer:

First, the new reality has altered the theatrics of therapy in ways that make both sides of the encounter aware of how much of psychotherapy is theatre to begin with. 

Apparently, the notion of a reciprocal exchange of thoughts, feelings and information has never been part of the therapy playbook. Nor is it at play in the theatre.

With the analyst sitting behind the patient, no reciprocity was possible or even desired. With one person doing all the talking, it is quickly going to feel like a dramatic performance. Looking someone in the eye, interaction face to face, these were proscribed by Freud-- apparently, by his admission, because he didn’t like to be looked at.

In the new age of teletherapy therapists are now being traumatized by the knowledge that their patients can actually look at them. Yikes.

Gopnik explains:

Like other therapists, the first thing that she mentions is not how differently she now sees her patients but how newly conscious she is of them seeing her.

Psychoanalysts in particular are very conscious of being in character, of playing a part. Apparently they trained in bad method acting class, and feel compelled to hide their faces and to mask their emotions.

“I spent a day doing my work and I wasn’t wearing shoes,” the analyst Mark Gerald admits. But, he realized, “if you’re a psychoanalyst you know that whatever you are wearing or not wearing is somehow playing a part. We’re the people who believe in the power of the invisible parts of the iceberg. Anyway, some of my patients are actually staying on the couch while they’re on the phone. It was part of their commitment. So I put back on my shoes. Shoes were a way of honoring the work.”

Staying on the couch makes you supine. Is that the best position from which to engage meaningful work? Besides, it is generally considered a sign of weak character.

Gerald, who is also a photographer, is an expert on the significance of the empty offices. Last year, he published a book of photographs documenting analysts’ offices across the world. Hovering around his photographs is the possibility that the psychoanalytic imperium, already faltering in New York under the twin pressures of skeptical insurance companies and changing intellectual fashion, may, in the face of the pandemic, be coming to an end—with all those offices soon to be abandoned, like forgotten Egyptian tombs.

Obviously, these therapists are not used to being looked at. They have never had face.They do not give their patients face. So, the whole process becomes extremely awkward. Precious few occupations allow this level of disrespect:

In remote therapy sessions, with the loss of familiarly structured therapeutic spaces, a kind of staring contest takes place. Patients may be startled to see a therapist in her home, but it’s nothing compared with the surprise therapists sometimes feel at seeing how their patients actually live.

And this:

Leonard Groopman, a psychiatrist affiliated with Weill Cornell, puts it bluntly: “You’re full frontal now for forty-five minutes. It adds hysteria to an already hysterical situation.”

Of course, canny analysts understand that Freudian practice began with hysteria. Despite the fact that Freud’s accounts of his treatment of hysterics were a fraud. Despite the fact that the social contagion of hysteria disappeared with the early years of the twentieth century, psychoanalysts cling to it, like a transitional object from their childhood.

Therapists are also fascinated to see their patients’ faces.

Because I can see their faces closer up, there’s an intensity. I can see the tears; I can hear the cracks in the voices. There’s something about seeing anxiety not in person that’s very strong and moving. It’s almost like interviewing kidnap victims or hostages. It’s also much harder to do a session on video—partly because I hate looking at myself, and I’ve gotta look at that all day. You have a mask of invisibility that you impose on yourself, and suddenly you’re seeing yourself seeing your patient, and it’s disconcerting, to say the least. ‘I look like that?’ You imagine an aura of empathy, and what you see is more like indifference shading into worry.”

Trust me, there is nothing intrinsically disconcerting at looking people in the eye. If these therapists think that it is, perhaps they need more therapy.

As it happens, some therapists are abandoning the therapy model for a more practical and useful coaching model:

Jaime Grodzicki, a psychiatrist who specializes in addiction, says that pandemic conditions have led him to combine a classic “analytic” model with a “coaching” model: he is available to his patients whenever they need him, and aims to talk them through daily crises rather than to guide them through a long-term program of insight. “For a population who self-medicate through anxiety, having the anxiety and the availability of the substance is a dangerous combination,” he says, noting that the wine-and-spirits stores of New York remain open, and many deliver.