One of the most important trends in psychotherapy in recent years has been the appropriation of Skype as a medium for therapeutic encounter between therapist and patient. No longer does a patient have to be physically present in juxtaposition with a therapist in the therapist’s office. The patient can be hundreds or thousands of miles away from the therapist and still engage in the focused conversation, that, whatever the structure of the therapy, will hopefully transform the patient so that his symptoms and sources of suffering are diminished or even eliminated. The idea is that the physical presence of the therapist is not required. What is required is the visual image combined with the vocal transmission of the therapist.
Among other things, Skype allows some people in isolated communities to see therapists and other people to continue with a therapist with whom they have been making progress, even though they have to move to another city. It allows people who have different kinds of emotional impairments to see a therapist, even though such people would find it psychologically impossible to actually make a trip to a therapist’s physical office. Someone with agoraphobia or a crippling manifestation of obsessive-compulsive disorder, for instance. Of course, many people just do Skype therapy out of convenience. Supposedly, they can have all the benefits of psychotherapy from the comfort of their home or backyard. What difference does it make, after all, as long as one is still having a therapeutic experience with a therapist?
The answer is that the therapeutic encounter with a therapist on Skype is very different from such an encounter with a therapist in his office. And the therapist in the Skype presentation is not really the same therapist as the therapist seen in his physical office. More precisely, the experience of the therapist is not the same, because the therapist is not alone. He is merged with another complex entity. He is merged with the computer or smartphone. Because the therapist is on a computer or smartphone screen, he appears as a presence composed of discrete pixelated mini-figures against a vacuum background. The therapist lacks material substance. He is a vacuumized pixelated presence floating in space and not grounded in a physical office that can provide a template where therapist and patient can bond and commune, and where a therapist can make a deep therapeutic imprint that is preserved.
The screen acts as a barrier to organic grounding, but is a mirror for and model of the remote highly defined discrete mechanical processes of the computer. These processes merge in the flat remote pixilated image of the therapist, which has absorbed the machine presentation. The movable pixels in the therapists face – in his expression – are like the movable parts in a machine. So the patient is bonding with a machine image of his therapist. And the patient unconsciously imitates the fragmented remote presentation of his therapist on the screen. He unconsciously becomes more machine-like, even as he, the patient, absorbs the insights of his therapist.
On Skype, the deepest bonding, the deepest communion that a person can have in order to heal emotionally is done in a situation where there is no meaningful sensory bonding or sensory communion. The cognitive insights are given in a relative sensory vacuum. The cognitive capacities of the patient are stimulated in a remote mechanical way. Insight data are absorbed. Modalities of mental processes are created that mimic the machine processes of the computer on which the therapeutic experience for the patient is initiated. Healing is configured such that , with the mirroring and modeling from the computer aspect of the therapeutic experience, the patient develops an aspect of flatness and remoteness as part of his healing to become a more functioning independent person. And a pixilated presence of a therapist leads to a tendency to absorb lots of mini discrete data – lots of isolated insights or directions for actions without necessarily putting them all together effectively into a coherent self.
Psychotherapy should not just be an encounter with a semblance of the presence of a therapist. It is important for it be conducted in a good comfortable office, ideally one that reflects the decorative tastes of the therapist. In such an office, there is a sensory immediacy to the connection that can be created between the therapist and the patient. A properly created office is a template that allows not only for the therapist to leave the imprint of his insights on the patient, but also one where the patient feels comfortable enough to make himself unusually vulnerable by opening himself up to the transformative effect of the therapist’s insights. The office should offer a sensory backdrop of comfortable blendable continual decorative stimuli to create the experience of a good grounded template.
This kind of experience is simply not possible in a Skype-based therapy. The patient is in the comfort of his home or his yard, and I would suggest that by not moving himself into his therapist’s physical territory, he is able to maintain the internal mental furniture of his defenses, just as he is able to sit in the protective backdrop of his own physical surroundings. In other words, he is less vulnerable but also, less open to the transformative effect of his therapist’s insights.
There is another aspect of the therapeutic interaction that is also less available in a Skype encounter. On a focused screen, one is not as likely to pick up the full nuances of another person’s body language. This makes it particularly more difficult for a therapist to understand different levels of meaning in what a patient is saying. It also makes it more difficult for the patient to pick up cues such as the calm confidence that allows him to appreciate the authority behind the therapist’s insights. Also, cues of quiet warmth and concern create the foundation upon which both mirroring and modeling can take place. In mirroring, a patient sees himself through the therapist’s reactions. In modeling, a person models himself after the therapist.
The therapist’s whole body gives a kind of physical context, a visual grounding for his insights much the way his office does. But on a Skype screen, the body is cut off, truncated, a vacuumized figure fragment floating in the vacuum space of the vacuum screen along with the vacuumized figure fragments of pieces of furniture and other artifacts that are floating on the screen. It is not a propitious configuration of therapist and accoutrements with regard to setting up a meaningful connection between therapist and patient.
Perhaps the limitations I have pointed out in Skype connections between therapist and patient can also be said to apply, to a certain extent, to any social connection that is carried out on Skype. Yes, it is nice to see people who are physically far away and talk with them. But the relationship is subtly transformed. A Skype person image is a two-dimensional, non-substantial, vacuumized image that simply does not allow for full communication and full communion. There is something unreal, ethereal about a Skype image. It is difficult for people to leave meaningful psychological imprints without the three-dimensional sensory component. The discrete verbal messages are transmitted, but not so much the grounded non-verbal messages. It is hard to make or receive a full personal imprint in connection to a person experienced as a bundle of pixels. The vacuumized fragmented two-dimensional image becomes part of the message and also a part of the internalized self-image.
Whenever possible, a person should avoid long-term Skype therapy relationships and, even if it means a certain amount of travel, should opt for a three-dimensional primary experience encounter with a therapist in his office. A Skype therapy is a therapy with a built-in distorted presentation of the therapist. This distorted presentation has long-term unanticipated consequences that lead to the opposite of an organic mental health.
The topic for this article was suggested to me by Dr. Jorge Cappon.
© 2013 Laurence Mesirow