Bodies in the room
Bodies in the room: keeping talk therapy real
Sherry Turkle, Gillian Isaacs Russell, Todd Essig
Faced with the prospect of losing her health care, a millenial offers a guide for therapy-on-a-budget: her thoughts turn to timing (try once a month) and from there to technology: “You can talk about . . . switching your sessions to Skype or email. Similarly, online therapy services like BetterHelp, 7 Cups of Tea, BlahTherapyand Talkspaceare effective alternatives. Anything is negotiable.”[1]
These days, many therapists seem to agree. With Skype, FaceTime, text, and email, no therapy needs to be constrained by bodies in the room.[2]The temptation to turn to online therapy extends across all branches of the profession, and across all therapeutic “ideologies,” from cognitive behavioral therapists to psychoanalysts. Yes, even psychoanalysts, who for generations, have written most movingly about the importance of physical presence in the therapeutic exchange have begun to treat patients and train analysts remotely. When the Tavistock clinic, home to psychoanalytic legends, including Michael Balint, Wilfred Bion, and John Bowlby, proudly announced their “ground-breaking new service offering couples and individuals online therapy via webcam,” it feels to many like the equivalent of an historical imprimatur. Turkle sighs, “An owl from Hogwarts.”
Of course, doing therapy sessions on the phone has been standard practice for decades.Many therapists felt it served them well during vacations, for clients whose work involved frequent travel, or when clients moved and decided to continue to work in established relationships. More recently, however, a sometimes convenience has escalated for many into a way of life. Therapists justify the remote lifestyle: Skype and FaceTime make it possible to treat clients from any part of the world. One need no longer have a local practice in any sense. If you work in an urban area with a lot of competition, remote work can help to insure a steady stream of patients. If you work in a remote area with few talk therapy prospects, technology can keep you in the game internationally.
But as convenience becomes commonplace, something shifts. A practice that was seen as better than nothing is no longer treated as a second best or temporary replacement. Some therapists it’s just as good as being there and others, think it’s better, citing, for example, the disinhibiting effects of talking to a screen. They argue that screen impersonality seems to provide a helpful context of “no judgment.”
But even as enthusiasm for remote therapy has increased, our own research with therapists, analysts, and patients, draws us back to the importance of bodies together in the room. It is supported by research on the power of nonverbal communication, of eye contact, of smell, gesture, touch, on the effects of occupying the same physical space. Research on the analytic process discern moments of nonverbal transformation that occur in microseconds. Crucial shared understandings between patient and analyst emerge in instantaneous moments of meeting.[3]As for those who tout the value of patients feeling “not judged” when they face therapists on a screen, we are skeptics: We see widespread confusion about feeling “no judgment” and the experience of not being in a safe relationship at all. The goal of treatment is not to have patients vent at screens; it is to have them risk angry feelings in a room with someone they trust.
After a long correspondence about the issue of human presence in psychotherapy, we are all finally are on the same panel at a psychoanalytic meeting whose theme is treatment at a distance. Our presentations complement each other: Turkle describes with concern how analysts talk to her about the “quickening” they feel when they do online treatment: As she sees it, the problem is that virtual connections have their own complex neurology; new feelings of intensity and heightened emotionality are common in all online interactions, from video games to math puzzles. Turkle fears that the analysts who sense a “quickening” are at risk of making naive equivalences, mistaking online excitement for deeper emotional connections. Russell remarks on the irony of senior analysts who will move from theoretical conversations about the countertransference to telling her how they are deepening the therapeutic relationship by ramping up their internet connections, camera quality, and screen size. Essig talks about the defeat of empathy when therapy moves to screens.
It seems to us that our remarks are treated as interesting, but oddly irrelevant. We compare notes and agree that when we argue for the importance of bodies in the room during psychotherapy, we often feel accused of trying to keep the field out of the 21st century, as though representing “the other side” of an argument that has already been decided. We understand what makes remote therapy so compelling and appealing in all practical terms. But we have a message that we want therapists and patients to take to heart: People and machines are not interchangeable. Ways of relating in therapy, venues and settings are not interchangeable. It is not true that in therapy, everything is negotiable. Not because good therapists shouldn’t be flexible and interested in meeting their patients’ needs. But because the virtual is not the real. A text is not a talk. A connection is not a conversation.
More than this, therapists have a crucial role to play in standing up for the value of physical presence in digital culture.[4]Stepping up to this job begins with questioning how you are using your devices with your patients.
For one thing, if you use a device to communicate with your patient or with your therapist, the device itself distracts you. Research shows that even a device turned off and turned face down on a table will reduce the level of intimacy of what is discussed in a conversation as well as the empathic connection of the participants.[5]
Our devices demand that we focus on them. We take our attention off ourselves as well as each other. Therapists and patients working online report a fear of the silences that are part of the natural unfolding of a treatment. A 28 year old patient, says, “ I have such a high level of anxiety that something is going to go wrong that it stops the flow. On Skype I find it so much harder to be silent. If I’m quiet, you might think that I’ve dropped off the edge of the universe.”[6]
Technology is underming our sensitivity to the importance of presence. Winnicott once said, “the object, if it is to be used, must necessarily be real in the sense of being part of shared reality,”[7]and of course, by “the object,’ he meant the therapist. Computer scientists who have devoted their careers to perfecting a sense of online presence say it cannot yet be consistently achieved.[8]Even the best shared online experiences leaves each participant with a certain sense of isolation.
Of course, a therapist working online can give advice, good counsel, and support. But what chance can a therapist have to do the deeper work if neither therapist nor patient feels they share a working environment of mutual understanding, where small gestures can be understood, where small changes can be appreciated? Online, on some level, they know they are acting in a simulation protected by distance and the barrier of the screen.
Needless to say, with all of this going on, it is a delicate operation to move therapy out of the consulting room and onto a screen just because it makes life easy and just because we can.
And yet, this is more or less where the field is at. Why are we so eager? Beyond all the reasons of finance and convenience, there is how screens allow us to escape the demands that doing therapy puts on our bodies. Perhaps we have always wanted to run from our bodies, from the anxieties of being together in this messy way with our patients in the consulting room. And now technology makes it possible.
Doing therapy is hard.It’s hard to sit with pain and anger. It is hard to fight sleepiness and boredom and the desire to yawn. It is hard to bear the patient’s scrutiny.
Taking the patient out of the room and onto FaceTime or Skype eases much of this stress. One therapist talks about Skype as an outright defense: “Sometimes I am filled with profound countertransference reactions, like terror or grief. It’s easier with Skype: they [the patients] can hurt you less — and they’re probably saying the same thing!” This is clearly a defense, but he’s not defensive because these days, technology in the consulting room is socially acceptable. If you are an analyst, you can even reimagine theory to make it seem that psychoanalysis has always been waiting for this new kind of treatment. Putting the analyst behind the patient was to facilitate free association. Taking the analyst out of the room facilitates it even more.
What begins as an experiment with remote therapy because someone is ill, or on a holiday, or a business trip, becomes a preferred way of working. Because then, our out of town patient returns and it simply is easier for them to call in because they are busy professionals and it is hard for them to get crosstown to see us. Or, we would like the freedom to travel and continue our practices. So “better than nothing” becomes simply better.
This pattern of “better than nothing” to “better than anything” is classic in the history of technology where robotic companions for the elderly for example, are first justified with the excuse that “there is nobody there to do these jobs” and then, they are touted as doing a better job than any human being could ever do. They are more patient, they never get angry, they are never bored, they will never die. We are at that kind of moment with artificial intelligence programs as psychotherapists.
At first, the idea of artificial therapists was something of a joke, as people laughed about telling their troubles to Siri. But now, there is the WoeBot, not a joke at all, but an AI program that is marketed unapologetically as a dialogue-based therapist.[9]You tell WoeBot your troubles and it does the best it can with you. We are no longer dealing in the realm of artificial intelligence. Now we are talking about a new AI, far more ambitious: artificial intimacy. More ambitious and more undermining of what is unique not only in therapy but in human empathy. A child playing with a chess playing robot may experience authentic artificial intelligence. A child getting advice from an artificial counselor is entering into a world of as if where there is no authenticity and certain damage.
Our story began with a young woman treating the presence of human therapists as though they were interchangeable (if necessary) with their machines. With the WoeBot we treat machines as if they were humans. Indeed, the CEO of the company that manufactures the WoeBot, Alison Darcy, is explicit about the arc that for her, takes the “better than nothing” WoeBot (a program that is there for you if no human therapist is available) to becoming “better than anything,” a better therapist than any human being could ever be. Darcy, a psychologist, says, “It’s almost borderline illegal to say this in my profession, but there is a lot of noise in human relationships . . . . Noise is the fear of being judged. That’s what stigma really is.”[10]There are so many children who enjoy venting to Siri and there parents are pleased, saying: “there are no judgements there.” But also, no relationships. There are so many therapists who boast that their patients are freer to share their feelings in online therapy for the same reasons.
As for the woman who used technology to find a therapist, she ended up with “leftovers,” as one often does on a dating app. So, she sends the psychologist a text message and she “ghosts” the eating disorder counselor, Internet speak for just going silent, disappearing as though that person never existed. Her endgame says a lot. In a therapy where bodies are engaged, the patient learns how to say goodbye in a way that preserves what is most valuable in the relationship. Freud called it mourning. It hurts and leaves you stronger and more alive. It’s not likely to happen if you text your goodbye. Or ghost.
Talk therapy has had a rough half century. So has talking. But psychotherapists are experts at the kind of talk that digital culture needs most, the kind of talk in which we give each other full attention, the kind of talk that’s relational rather than transactional.
The culture of therapy affects our culture as a whole. How we seek help and what we expect it to look like, changes our values in a broader way. Right now, digital culture closes down the questions that talk therapy knows how to open up. We’re being challenged to affirm the values that are at the core of what it means to be human and to stand up for a kind of therapeutic work designed to speak most directly to our full capacity for meaning, empathy, and relationship. And for the untidiness that all of these bring.
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Sherry Turkle is Abby Rockefeller Mauzé Professor of the Social Studies of Science and Technology at MIT, affiliate member of the Boston Psychoanalytic Society and Institute, and the author, most recently, of Reclaiming Conversation: The Power of Talk in a Digital Age (New York: Penguin, 2015).
Gillian Isaacs Russell, Ph.D. is a U.K. trained psychoanalyst. Her book,Screen Relations: The Limits of Computer-Mediated Psychoanalysis and Psychotherapy was published by Karnac Books in 2015.
Todd Essig is a clinical psychologist and psychoanalyst in private practice and a Training and Supervising Psychoanalyst at the William Alanson White Institute in New York City and a clinical Assistant Professor in Psychiatry at New York Medical College.
[1]New York Times, July 17, 2017, “How to Find the Right Therapist: Searching for the Right Therapist is Sort of Like Dating. Marissa Miller.”
[2]http://dx.doi.org/10.1080/1551806X.2017.1304122
[3]Stern, D.N., Sander, L.W., Nahum, J.P., Harrison, A.M., Lyons-Ruth, K., Morgan, A.C., Bruschweilerstern, N. and Tronick, E.Z.(1998). Non-Interpretive Mechanisms in Psychoanalytic Therapy: The ‘Something More’ Than Interpretation. Int. J. Psycho-Anal., 79:903–921
[4]https://psychotherapynetworker.org/magazine/article/1051/the-empathy-gapand Sherry Turkle Reclaiming Conversation: The Power of Talk in a Digital Age (New York: Penguin, 2015).
[5]Misra, S., Cheng, L., Genevie, J., Yuan, M. (2014). The iPhone effect: the quality of in-person social interactions in the presence of mobile devices. Environment and Behavior, 1–24: doi: 10.1177/0013916514539755.
[6]Gillian Isaacs Russell, Screen Relations: The Limits of Computer Mediated Psychoanalysis and Psychotherapy (London: Karnac Books, 2015).
[7]Winnicott, D. W. (1969). The use of an object. International Journal of Psychoanalysis, 50: 711–716.
[8]Campanella Bracken, C., & Skalski, P. D. (Eds.) (2010). Immersed in Media: Telepresence in Everyday Life. New York: Routledge.
[9]http://www.wbur.org/onpoint/2017/06/20/the-future-of-mental-health-therapy
[10]https://www.wired.com/2017/06/facebook-messenger-woebot-chatbot-therapist/
