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
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