Remote Therapy Research

A research on distance psychoanalysis


RISKS AND OPPORTUNITIES OF REMOTE THERAPY

How the evolution of the convergent communication technologies and the increased Internet penetration impact the psychoanalytic process of the psychoanalytic setting when a remote therapy is performed. An study about the strictures imposed by the technology.

This research has been funded with a Grant of the IPA, and performed by:


Principal Investigator: Analy Werbin, MD, APA and Invitee of the APM, (Spain)

Co-investigator and Clinical Supervisor: Felix Gimenez Noble, MD, APA, (Argentina)

Co-Investigators: Marcela Dal Verme, APA, (Argentina); Diana Sahovaler de Litvinoff, APA (Argentina); Martina Bourdet, APM, (Spain)

Statistical Consultant: George Ambort, (Switzerland)

Technology Consultant: Julio Hirsch-Hardy, (Spain)

Grant Administrators: APA, APM.



General Considerations, an update at the end of the research.

In order to deepen the clinical analysis, the study was extended for another two years. However the additional researchers’ efforts have not been charged to the funds of the Grant.

Financials with the Grant Administrators were closed in Q2 2016, with a positive balance on favor of the IPA, and researchers continued working until mid Q2 2018 by their own means until closing the clinical cases with more accurate conclusions.

It must be noted that since the beginning of the research and during these last four years, some aspects of the telecommunications technology have evolved in several senses, and penetration has increased among worldwide population. 

However the intrinsic of the technology remains the same as compared to the moment of starting this research on remote therapies, and the conclusions of this report were not altered by the path of time.

Increased broadband due to wireless evolution and the more frequent availability and use of fiber optics, have enhanced the way we may communicate by videoconferencing facilitating the exercise of remote therapies. On the other hand increased penetration and familiarization with Internet, especially due to 4G mobiles, allows us to infer that there was a notorious impact in psychoanalysts now doing remote therapies much more than when this research was started. This assumption is reinforced by the ideas exchanged in both Boston and Buenos Aires IPA Congresses. In this aspect, we may conclude that the survey this research conducted among IPA members, would have given different results today in favor of the percentage of therapists increasingly using current available technologies to perform remote therapies.



ABSTRACT

The main focus of this study is to assess the validity of the psychoanalytical setting in the remote therapies, and if a distance psychoanalytic therapy can be performed online using current telecommunication technologies. The increased implication of Internet in the psychoanalytical praxis is being object of several controversies regarding the differences between face-to-face and remote (online) therapies. This investigation, after three years of clinical research backed up by a survey performed among IPA members, and assessments of the evolution of the new patterns of human interaction, has concluded that the psychoanalytical process in remote therapies can be exercised as well as in the face-to-face therapies, given the fact that the physical absence of the body is not a fundamental issue: the Freudian process deals with emotions, desires and phantasies rather than with the body, which would be the case of the Reichian and post-Reichian therapies. Through interviews and surveys with IPA members, and the supervised follow up of clinical cases, the research team has confirmed the hypothesis of the validity of the Freudian process in remote therapies and concludes that those assumptions regarding the differences of face-to-face and remote therapies vis-à-vis the execution of the psychoanalytical process, are incorrect. This research considers that a psychoanalytical therapy can be performed in a remote setting since it sustains an authentic psychoanalytical process according to the classical techniques of the Freudian setting, in an environment in which the psychoanalysis encourage the learning of new paradigms conducive to continuous and increased socio-cultural and scientific changes.


INTRODUCTION

The first interrogation of this research was if the communication means used in the remote therapies -the fact that patient and analysis are not in the same room, the non existence of direct visual contact or not using the couch,- could affect the essence of the psychoanalytical treatment.

The expression of the neurosis has different languages that should be considered. The bottom line is if the patient get into the analysis o not. Freud has established in ‘Remembering, Repetition, and Working-Through’ what we can define as the registered mark of the psychoanalysis: Durcharbeiten is what differences psychoanalysis from other therapies when it implies the need of overcome the resistance of the resistance: Wiederholungszwang, the compulsion to repeat.

As an starting point, and under the understanding that distance and in-person are two completely different situations, the research consider as priority studying if a psychoanalytical transference is established when performing a distance treatment, and if that transference is similar to that happening in a face-to-face treatment being patient and analysis in the same room; it was also consider a priority to study if the fundamental rules of Freudian psychoanalysis are fulfilled, namely the free association and the evenly-suspended attention.

Only psychoanalytical therapies were addressed in this research, both in the survey and in clinical cases, leaving aside remote treatment using non-psychoanalytical therapies. Neither had this research dealt with remote supervisions nor with training analysis. This research has not done any assessment or analysis regarding previous studies related to ‘remote psychoanalysis’ since with few exceptions we haven’t found in-depth research works. Most of the ‘remote therapies’ works deal with other therapies than psychoanalysis such as cognitive, systemic, or gestalt therapies, to name just a few. Compilations of articles like Psychoanalysis Online (Jill Savege Scharff et altri) contain several studies and works but can be hardly consider as research efforts; they are rather studies of individual clinical cases. An exception is Scharff’s Psychoanalysis Online 3, but it was released after we finished the investigation and were writing the final report. That book does have some interesting insights about the setting in remote therapies. Regarding works that are opposed to distance therapies or discussing the ‘virtual’ setting as opposed to the ‘classical’ setting, few things of real value have been written and published so far. There are only few works about security issues in the remote therapies (issues that are actually similar to any micro that can be bugged in an office), and critical reproaching silence is the usual reaction to remote psychoanalysis rather than a serious academic study.

Historical Context. This work has been done in an historical moment characterized by the change produced by the convergence of the telecommunications technologies, which have drastically modified the way we relate to each other. For the purpose of this research we define ‘convergence technologies’ as the simultaneous exchange of voice, data and video on the same communication channel interacting bi-directionally. On top of the ongoing revolution started by Facebook, Google Hangouts, What’s App, Twitter, Face Time, Skype, Instagram and many other communication means, in the next few years we will witness an even bigger transformation whose reach is still hard to assess in relation to its impact in the psychoanalysis practice: the new networks will transform the way we perceive the world that surround us and the way we relate to each other. In terms of telecommunications technologies, the 5th generation (5G) networks will transform the current reality in a connected reality. A new reality in which all objects and persons will be able to be interconnected conforming a single totality. The Internet will be fully mobile and nomad, allowing connecting all inhabitants of the planet among them and with an estimate of one thousand objects per person, meaning an impressive amount of one trillion connected objects. Each person will be able to be connected to their physicians, relatives, friends, coworkers, clients and suppliers, security services, car, favorite supermarket, leisure places, subway, airports, fridge and other home appliances… in brief, to any object and person that may have an interest to us. This is actually happening today but we’re just seeing the beginning of new communications patterns. The communication speed of 5G networks is extremely high: fifteen years ago it took 26 hours to download a movie, now it takes about 6 minutes and with 5G it will take only one second, as it is already happening in Oulu in Finland where 5G networks are being tested, as well as in Seoul, where the first trial with hologram international call is being done. The implementation of these technologies will allow confirming a very special setting where through a complete hologram video call, analyst and patient will be able to meet remotely in a real size in real time. And Skype or future similar systems will be such that the sound will be tridimensional in terms of high fidelity, the image perfect, and without any chance of interruption of the communication. The analyst will have the chance to close the eyes in that setting perceiving the sensation that the patient is actually present in his room; with a hologram that sensation will be almost close to reality.

For some people these forecasted changes might look like science fiction, but just recall that only twenty years ago Internet started to be available to the consumers (1996), people were using mobile phones having the size of a shoe, interactive text messaging did not exist and there were no chances to display photos in the phone… and nowadays we’re using phones that at a cost of less than $200 have a processing power similar to a computer of the mid sixties that had a cost of over 4 million dollars. Just remember and take into account that once invented the radio it took 50 years to have a radio equipment deployment to 50 million people while an application like WhatsApp reached 50 million users in one week after being launched.

This is the world we live in. For those that are at least two generations younger than the Millennium generation, it is hard to understand that this present is a pale representation of the near future in terms of digital communications and social intercommunication habits.

This is the context in which we have done our research to assess the validity of remote psychoanalysis, and to understand how the analyst of tomorrow should be prepared to work within five years from now with a young of the Z generation that has a multitasking skill that few of us possess. How should an analyst be trained to acquire and process information that no previous generation has had? If a young of the current generation perceived and understand technology and its swift changes and advances, we questioned ourselves how will interact an analyst with such a patient, a patient of the generation Z, having been trained in the Eitington tripartite model developed in Berlin in 1920 and adopted by the IPA in 1925?

When analyzing the replies to a survey we have conducted as art of this research we found a large number of negative positions towards remote therapy. The survey was sent to all members and candidates of the IPA, and although we concluded that 35% of the surveyed analysts are performing remote therapies and another 14% is planning to do in the near future, 41% were opposed to all type of remote treatments – 22% definitively opposed and 19% with serious doubts. The common denominator of the answers was ‘This is not psychoanalysis’. When people against were asked about the reason, arguments were of the type: ‘because I don’t think it should be done’, ‘it is unethical’, ‘it is against my professional commitments’, ‘remote practice is not allowed by the association I belong to’, ‘the world is already immersed is a loss of personal contact: remote psychoanalysis will harm humanity’, I do not believe in remote psychoanalysis: transference occurs in the analytical setting because it requires sensorial elements for a formal regression’,  ‘This is not psychoanalysis and if it is psychotherapy I’m not interest in’, ‘I don’t believe an analyst can get into the complex of the mind, including suspended attention and the exercise of neutrality when so many technological interfaces makes impossible the interpersonal relationship’, ‘body language is lost in remote analysis, as well as the physical and emotional atmosphere in the room’…

Our investigation, based on clinical cases, specially addressed these comments contrary to remote psychoanalysis under the understanding that it should be assessed the validity of the setting in distance psychoanalysis.  We found out that there was a common denominator in those comments: the questioning of the lack of body presence or, in other words, working in a setting different that the one they considered it should be.

When correlating answers with years of analytic experience, we found out that the vast majority of people opposed to remote psychoanalysis were members with more than 25 years of experience, meaning they probably are over 55 years old in average. It is has to be noted in this sense, that IPA has openly expressed concerns about the aging of the members’ population.

In this framework it is clear that the role of the therapeutic setting in the history of psychoanalysis is something that was somehow understood for a long time and therefore little was written about it. Since the setting describes a necessary environment to allow the analytical process to occur, it was simply seen as a structure, a physical prerequisite added to a treatment contract and a behavioral code for both patient and analyst, without actually deepening in the special meaning of the setting. Perhaps because it wasn’t necessary to discuss about it: the setting always existed, since the beginning and in all situations. Freud was the first in describing the role of the setting in his Papers on Technique as a basic treatment platform, but Bleger and Baranger, among others, studied the function of the setting and its psychodynamic meaning in depth years later. And today we may concur that although being clear that, as Freud pointed out, the setting itself is not the focus of the treatment, we may say that it is the basis around which the rest is constructed. The setting refers to the basic rules, the rules of the psychoanalytic game allowing the development of the therapeutic process and providing the optimal circumstances to profit transference phenomena. Being the setting defined as the classical Freudian method, or as Winicott pointed out, as the sum of all the technical details, or as the constants framing the process according to Bleger, our investigation focused in assessing if the practice of a remote psychoanalysis impacts the setting in such a way that makes impossible the analytic process, or if the impact is rather not negative and the psychoanalytic process can occur in a remote therapy. The occurrence of the psychoanalytic process in remote therapies was in fact the hypothesis of our investigation and assessed through the follow up of clinical cases during periods of over five years.

Importance. At this moment of the introduction it is important to point out why the controversial theme of the distance psychoanalysis should be studied. As we said, the humanity is evolving to an interconnected society whose youngest members –those who are our future patients currently representing 1.6 billion human beings, almost 22% of the worldwide population- are members of the Generation Z who were born immersed in technology represented by common tools of daily use.  Therefore it is impossible to avoid what that fact implies in terms of the exercise of the psychoanalytic practice. It is not any longer about remotely treating a patient that can’t physically go to the psychoanalysis office because he’s ill or traveling or moved to another town, or because is living in a region where no analysis is practicing. Nowadays, and specially in the near future, it will be also and additionally about patients that interrelate with technological means and that may even prefer to interact with the analyst on a remote basis.

Leon Saul, a prophetic forefather in the use of the telephone in psychoanalysis in the early 50s asked himself -60 years ago- if the idea of using a communication technology such as the telephone as a mean to interact with the patient would trigger a horrify resistance within the psychoanalytic community, or if perhaps the majority of the psychoanalysts would approve it anticipating experiences with televisual communications once they become available. Leon Saul reaffirmed the idea that the technology can be a mean to achieve an end, and that it was possible to talk over the telephone line about specific transference matters, making possible its fulfillment and later reassuming face-to-face sessions.


Limitations. We recognize two limitations in the scope of this investigation. On the one hand we believe it should be extended in time since two years is a short time to make a follow up and control of the clinical cases of treatments initiated at the beginning of the research (although most of the cases are remote clinical treatments initiated years before starting this research) . This was partially overcome since we have extended for another year the study of those clinical cases until actually writing tis report, and therefore having had more insights about the clinical cases.  


On the other hand there was a second limitation, which is in reference to the survey we have conducted. The universe we have addressed in our survey was composed only by members and candidates of the IPA, which leaves thousands of analysts out of the survey, which eventually may produce some bias in the results. Effectively, thousands of analysts were not considered in the sample taking into account that the survey has not been mailed to members of associations such as the Division 39 of the American Psychology Association (APA), the World Association of Psychoanalysts (WAP), the International Association of Analytical Psychology (IAAP) and many other that in total are composed by a population of psychoanalysts much larger than the IPA. Having into account that institutions such as the American Psychology Association issued five years ago guidelines for the execution of remote therapies –to which the Division 39 has adhered- it is possible that the results of the survey would have been different by indicating a much larger am0unt of psychoanalysts considering remote psychoanalysis as a viable process.

 

Methods

The methodology of this investigation was based in two dimensions. On the one hand a survey, both quantitative and qualitative, was distributed among member of the IPA. On the other hand, the members of the research team have worked in the study of clinical cases, treating patients remotely, and controlling selected sessions with one of the members of the team.

The objective of the survey was to ask the opinion of IPA membership relative to the practice of remote psychoanalysis, specifically gathering information about their assessment on the viability of the remote setting and the feasibility of a productive encounter among analyst and patient when using remote communication technologies.

When it comes to the objective of the control of the clinical cases, it was based in analyzing and controlling the adequacy of the remote setting and the viability of the development of the analytical process.


Survey. The survey on Remote Psychoanalysis was designed by the research team and published in the official website of this investigation, www.remotetherapy.net. IPA has sent an email to all full members and candidates inviting to fill out the survey and indicating the link to access it. Shortly before the deadline to submit the survey completed, IPA sent a second reminder to increase submissions.

Universe and answer ratios. At the time of releasing the survey IPA had a total membership (including candidates) of 15,319 analysts. Invitation emails were successfully sent 13,143, meaning 85.8% of the total membership. Bounced emails (2,176) were due to different reasons such as ‘mailbox full’, ‘rejected by anti-spam systems’, and ’wrong address’. 37.9% of successfully sent emails were opened (4,981). The survey was filled out and submitted by 1,171 analysts. That figure represents 23.5% of those who opened the IPA’s invitation, 8.9% of the analysts that received the email, and 7.7% of the total membership. This last percentage was actually the sample of the survey. It is interesting to note that these percentages are slightly higher than the average response of regular emails sent by IPA, indicating a manifestation of high interest in this matter. According to the criteria and objectives of this research, it is indeed a representative sample, sufficient to identify attitudes and trends towards remote psychoanalysis. The sample was representative having into account that we launched the survey targeting a dispersion error not larger than 3% with a confidence interval of 95%, which would have required 950 submissions, a figure that is below to the actual figure of the sample (1,171).

 

Results of the Survey.

Quantitative analysis: Responses per region was between 8% and 15% in European Countries, US and Canada, and much lower in Latin American countries (between 4 and 6%).  45% of the respondents were medical doctors and 45% psychologists. In terms of years of practice, results were coherent with something that is a concern within the IPA: the aging of the membership population. 53% of the respondents had over 20 years of practice. We mention this fact specially because that age range probably conditions the use of communications technologies and may stress a negative perception of remote therapies. Response distribution among full members and candidates registered however an odd result: although the distribution of members/candidates is 72%/28% within IPA, the response distribution was inverse, 86%/14%. A subjective conclusion might be that candidates, being younger, have less conflicts and prejudices with remote psychoanalysis in relation to more aged members. But this is something that has to be studied further in order to reach a sound conclusion, and this was beyond the scope of this research.

Only 1% of the sample does not have a PC; 99% uses either a PC or a tablet. 91.5% of the sample uses smart phones, according to this distribution: iPhone 53.2%, Android 18.2%, Windows 6%, Blackberry 5.4%, other/don’t know 17.2%.

Skype and other video conferencing media are used by 67.2% of the sample. Chats are used by 67.2% of which Skype represents 53.9%. Chat was used by 26.8% on mobile phones and 13.9% on PC. 13.5% of the respondents have a website while those having Facebook and Twitter are 25.1% and 6.6%, respectively.

62.2% uses some kind of technology to perform remote therapies, of which 4.3% performs a mix of remote and face-to-face therapies. 37.8% indicates that have never performed any kind of remote therapies.

Of those who do remote therapies (62.2% of the sample), 8% uses email, 1.6% use chat, 48.9% uses phone, and 55% video conferencing. Please note that in this case multiple answers were allowed and therefore the total is larger than 100%.

Qualitative analysis. Using structured questions and free answer possibilities, the survey assessed the perception of the sample regarding the position of the respective component association towards remote therapies and if they conform a legit psychoanalysis. 14% indicated that there was a explicit agreement; 40% indicated that their respective associations they belong were against; 30% were studying the matter; 4% were indifferent; and 12% did not answer or did not know. These results are coherent with the apparently little interest in most of the component associations to analyze remote analysis by conforming study commissions or task forces. It is not the case of the IPA that is deepening in this conflictive matter and has addressed specially the subject in the Boston Congress, besides granting subsidies to this and to another group in US.

When analyzing answers and comments regarding the question whether remote therapy can be a psychoanalytic therapy, 22% opined ‘absolutely not’, 19% expressed doubts about it, 23% has no opinion and is thinking about, and 34% were in agreement that remote therapy can be a legit psychoanalysis therapy. When cross checking related but different questions we found out that 22% is against remote therapies since it is not psychoanalysis, while we also found out that 35% of the sample perform some kind of remote therapies and another 14% us planning to do it in the future. This is an indication that almost 50% of the sample is moving in the direction of performing remote therapies, and that there is an increased trends towards distance analysis. Another set of questions was related to when a remote therapy should be performed. Of those who agree with remote therapies or are planning to do it in the future, 24% had the opinion that it can be performed in any given situation as alternative to the face-to-face session, while 71% opined that it should be used only in special circumstances such as travel, sickness or change of place of residence.

When being asked about the inevitability of remote therapies, and considering the entire sample, 64% -no matter they agree or not with performing remote analysis,- indicated that it is in fact inevitable, while the remaining 36% indicated that communication technologies shouldn’t be used as a mean of doing remote psychoanalysis as a replacement of face-to-face sessions unless certain special circumstances are present.

In terms of legal matters, in several countries there are specific strictures that diminish the capability of performing remote therapies, whether due to lack of license in the place where the patient is located (34% of respondents indicated this restriction), or due to missing malpractice insurance (24% indicated that problem). In some countries, especially in United States some states are addressing these questions and starting to grant multi licenses; this is due to the fact that these strictures affect not only remote therapies but also many kinds of telemedicine practices, like remote chirurgic procedures using Da Vinci.

Regarding ethical matters, the main concern addressed by 93% of the respondents was that special care should be taken to avoid identity theft (phishing) when the media utilized can’t verify the identity of the patient (mail, video without using the camera, telephone, chat).

Although security and confidentiality is not assured when using technological means in remote therapies, 53% of the respondents concur that it is perhaps easier to install a microphone in a physical office (or to listen a conversation using a remote laser microphone pointing to the office window) than hacking a Skype conversation of intercepting a telephone conversation or chat.  If somebody (or a security agency) wants to listen a conversation in a physical office or a remote session, we all know it can be done if there’s a hidden agenda that motivates the intrusion.

In brief, the survey has shown that there’s an incremental trend in the use of remote therapies, and a considerable group of psychoanalysts are using it on a daily or weekly basis, although it is true that at the time of doing the survey almost 40% of the sample wasn’t doing remote therapies. We mention ‘at the time of the survey’ because it is clear that social media, telecommunications interactions that facilitate remote therapies are growing at an enormous speed.

 

Clinical cases

A total of thirteen patients were subject of distance analysis performed by the researchers. Some started long before this research, other started during this research and almost 80% are still ongoing during the writing of this report. During the research, another seven cases were incorporated in the phase two, an ongoing research not covered by the Grant.

The cases covered an ample spectrum of methodologies, including a mix a remote and face-to-face; email, telephone, videoconferencing, and combinations of the different unidirectional and bidirectional (synchronic) communications.

Recorded sessions, content of the analytical dialogue and thoughts and reflections of the respective analysts were supervised and controlled by one of the members of the research team, and results of the controls were discussed in monthly teleconference meetings among all members of the research team.

In order to have a representative sample, cases were selected covering an extensive variety of presumptive diagnostics such as anxiety, pathologic mourning, phobias, anguish neurosis, depression, bipolar disorder, and attention disorder.

A brief description of the thirteen cases follows:

All descriptions are timely related to the moment the first phase of the research has ended. Changes may have occurred since then.

Male Patient, married with children, 49 years old. Working for an NGO, in treatment since 2009 and ongoing.. Started with email without having had an initial face-to-face interview. After one year in treatment through email, analysis continues using videoconferencing (Skype) and, occasionally –when he’s on the road with no reliable Internet access- by telephone. Treatment started due to patient’s need to have a psychoanalytical support when traveling. During the treatment, the death of the parents triggers a pathological mourning. He is still in treatment with a market resolution progress, being able to travel without problems. The mourning process is evolving positively.


Single woman, 21 years old. She’s an homosexual student that shortly before starting treatment left the paternal house experiencing a neurotic’s anguish, moving to another town. After starting a face-to-face psychoanalytical treatment in her new location, she moved to another town to go on her studies in a different university, continuing the treatment by means of videoconferencing. Six month after the start of the remote therapy she returns to the paternal house restarting her studies in her hometown and alternates videoconferencing sessions with face-to-face when travelling to the town where the analyst resides. Ongoing treatment.


Single woman, 31 years old. She works online from her house. She starts with face-to-face sessions, manifesting a neurotic’s anguish and alcoholism. After moving to a different location the therapy continues remotely, using videoconferencing means. Seven months after initiating the treatment the patient reinitiate the studies and is still struggling against the alcohol addiction. 


Divorced woman, 47 years old, high school teacher. In treatment for five years, started as a face to face patient and has occasional remote video conferencing sessions: although living in the same city of the analyst, she ask for remote sessions when she’s unable to arrive in time to the analyst’s office. Mixing face to face and remote sessions she never missed one single session since she started treatment. Started the treatment due to depression and neurotic’s anguish. The treatment is still ongoing and she is solving several problems, not being depressed any longer, and for the first time in her life, she was able to experience orgasms.


50 years old single mother. She is a journalist that started remote treatment on the phone. Never had a face-to-face session and never met personally her analyst, whom she ‘found’ in the Internet. Started treatment due to insomnia and diuresis disorder. After a while sessions are alternatively performed on the phone and through videoconference. After five months she abandoned treatment, never solved any of her problems and ‘disappeared’ without paying the last sessions that were previously paid promptly by bank wire.


Married woman, 42 years old. Started treatment a year ago. She’s an artisan that started treatment a year ago with face-to-face sessions. She expresses to be depressed due to having emigrated from her country of origin. She continues with her treatment with remote sessions after moving to another city, having overcome her depression.


Divorced woman, 55 years old, sales woman experiencing depression and probably hallucinations. Her treatment last only one year: after starting face to face sessions, she continues by video conferencing once the analysts move to another location; but at some point she does not tolerate the moving of the analyst abandoning the treatment.


36 years old married woman with one son; unable to work in her profession after emigration to another country. Manifesting depression, she starts with face-to-face sessions shifting to video conferencing after moving to another country.  During the therapy she become pregnant. She quit treatment when husband, a medical doctor, refuse to go on paying for it.


Single woman, 43 years old. She starts treatment in face-to-face sessions. Being a sailor she continues with remote therapy when being onboard using whatever technological mean she has on hand –eMail, telephone or video conferencing. Being treated for anxiety and depression she does not evolve positively during her 3-years treatment. After that period she become jobless and abandons treatment not having the chance to go on paying for it.


Married patient, 45 years old. After having started treatment in face-to-face sessions, therapy continues using video conferencing due to a travel of the analyst. When the patient moves to the countryside, therapies go on using video conferencing. The reason of the patient for starting treatment was his inability to leave his wife, who he did not love any longer. Once his problem was elaborated he divorces his wife, and considers he not longer needs to be in treatment and travels to have a final closing face-to-face session.


Female patient, divorced, 55 years old, being treated by the analyst in a psychiatric institution with a Bipolar I diagnosis. When the analyst succeed in attaining her hospital discharge, patient continues in treatment with a mix of face-to-face and remote video conferencing sessions. Due to economic problems she abandons therapy due to financial reasons, one year after her discharge from the psychiatric institution, but having been fully reintegrated to social live, and working as a piano teacher.


25 years old patient, single, that starts a face-to-face treatment expressing relationship problems with his mother, with whom he lives at the time of starting therapy. He also express having attention disorders that impedes him to end university studies although he’s almost ending them. When the analyst travels therapy go on using video conferencing, assuring treatment continuity. Twenty months after having started therapy, and not having lost a single session, he managed to abandon the maternal house deciding to live with his girlfriend, and ended his studies. Treatment still go on mixing face-to.-face and remote sessions. He’s planning to move to another city to pursue postdoctoral studies, and will continue treatment with video conferencing.


Woman of 33 years old, single, independent professional. She was in treatment for two years, abandoning after failing to show up without giving any notice. She’s a patient with phobias and anxiety neurosis. During treatment she has alternated face-to-face and video conferencing sessions, always lying on couch.

 
Discussion

Following the results of the survey conducted, we conclude that almost 60% of the IPA members and candidates use some kind of remote therapy. Although it is not clear –and should be studied further- if remote therapies performed are in all cases a psychoanalytic framework or it are rather non psychoanalytical psychotherapies, it becomes clear that the growing trend is the use of converging telecommunication means in the performance of therapeutic sessions.

Analyzing the qualitative comments (an average of five comments per response received, conforming over five thousand qualitative comments) we may infer that a significant number of IPA members consider remote therapy is a viable therapy as part of their psychoanalytical practice. Many of these comments express positive experiences as far as concerned with the viability of the psychoanalytic process without negative impact on the framework. When assessing if there’s a real development of the psychoanalytic process the results of the qualitative comments are a mix of highly positive comments, positive with caution, skeptic, and frankly negative. A small percentage is firmly opposed in the qualitative comments to even consider doing remote therapies, a fact that may be due to a lack of adaptability to current and trendy use of technology, although this assessment should be studied further. Analysts are working in a technological environment that has evolved swiftly and dramatically, and we wonder up to which point analysts are adjusted to the socio-cultural changes that happened in the last ten years. It should be considered that these changes in the way we communicate each other, might have had strong effects on the psychoanalytic context, the method, treatment, body knowledge… and in the institutions.

Concepts like globalization, occupational changes, family structure, longevity, changes in the health systems, environmental changes, medical advances, massive deployment of technologies, massive education, drug endemic problems, are happening and changing at a fast pace in a frame in which technological and medical advances are happening every day. These immense and swift social transformations, which impacts our daily life, seems to be of lesser impact in the psychoanalytic since the treatment method and setting remains almost the same as it was in the last decades. Following many of the qualitative comments received, impact in our internal and interpersonal world should be a fundamental research target in the psychoanalytical research effort. However, many of the IPA’s component societies are apparently paying little attention to these changes. It might be concluded that there’s a tendency to shutting up in inaction having thoughts not adequate to contemporary times. It’s as if they were blaming the external world for the fateful unlucky of psychoanalysis in terms of its diminished penetration, resisting changes in the name of the golden mythological standards of the psychoanalytic purity. But it is also true that as an outcome of the analysis of the qualitative comments of the survey, it has been found that many IPA’s component societies and psychoanalysts are adopting a proactive attitude to encounter the contemporary doing a significant contribution to psychoanalysis by not only transmitting psychoanalytic knowledge but also creating new knowledge that are enriching psychoanalysis.

Monthly teleconferencing meetings were held by the research team discussing the clinical material observed by the supervisors.  When discussing the framework in remote therapy, it was concluded –following the analysis of the clinical cases- that the analytical process was viable without alterations of the Freudian framework, if privacy rules are observed and analyst is properly trained.

It was also concluded that most of the remote therapies are associated with and based on grounds of force majeure, such as migrations, moving, residence in countries with different languages, sickness, lack of analysts in the town of residence of the patient, temporary trips of either the patient or the analyst, etc., in which case the transference liaison imposes over the scenery change. In some cases –not very common- remote therapy can be an option of the patient, an approach that might be destined to preserve not transferred, certain phobic contents. In these cases, the therapy should develop parallel to the alleged horror to the contact, without ever going through it in order to work on the possible influx of a resistance that could recue the efficacy of the framework. It has also been concluded that in remote therapies it is important to dig deep in the analysis of the resistance respect to the effort to travel of those who live far away from the analyst office.

The main feature of psychoanalysis that distinguish it from any other psychotherapy is the need of working through, a technical phase destined to solve the compulsion to repeat, which becomes clear no matter if it is mediatized in face-to-face or in remote sessions.

It has also been noted in the study and discussion of the clinical cases, that the free association and the suspended attention, elements that produce an analysis, may imply that the transference of analysts and patients are present in a perceptual field that contain both: patient and analyst not only see and listen each other but they also feel the real presence of the other in the initial greeting and in the goodbye at the end of the session. We may therefore conclude that the presence of the body in the shared space configures a live space, where the interaction is direct without any mediation of interposed elements such as the technology. Notwithstanding, therapies mediated with technological means, such as videoconferencing, develop a virtual presence that validates the real distance: it is like being together, even in a virtual space.

In the observation of the clinical cases, case number 1 clearly and unequivocally indicates the viability of the psychoanalytical treatment precisely in a case where everything is mediated remotely, without face-to-face sessions: “during the first stage of his treatment a important change took place: it consisted in the fact that as the circumstances that determined his anguish emergency were analyzed, progressively determined the decrease of the anguish, until the anguish crisis felt disappeared when travelling himself or his wife. Therefore in both situations –his or her travel- the anguish emerged vis-à-vis the separation of the object, which was related to the death of his mother.  This modification wasn’t extraneous to the increment of the established transference, that was increasing as the analysis progressed.”

 

Conclusion


From the results obtained in the survey and the study and analysis of the clinical cases, performed before and during the research, and most still ongoing at the time of writing this report, we may say that remote psychoanalysis is viable. That is to say that connected by means of asynchrony interaction of telecommunications, being analyst and patient in different locations, an authentic psychoanalytic process may take place and develop in terms of the traditional psychoanalytic technique. We strongly believe it will redound in a necessary and positive update of the psychoanalytical process, now and in the future; helping to counter the frequent attacks psychoanalysis is suffering, and contributing to its expansion. It will depend of course in the ability of analysts and institutions to be adjourned to the new technologies with a creative and flexible approach, and adapting, if necessary the way we interact with the patients.