In recent weeks there has been a flurry of discussions on some professional email lists about managed care companies and insurance companies denying reimbursement for psychotherapy treatment, particularly for treatments involving session frequency of more than once weekly.

This is nothing new, and it is likely to continue or worsen, as health insurance and managed care companies use the excuse of reigning in out-of-control health care costs to eliminate as much treatment as they can. Even though there is no evidence to suggest that outpatient psychotherapy treatment has contributed significantly to the enormous growth of healthcare costs in general, and despite the fact that psychotherapy fees have tended to remain flat or even have declined in recent years, our area of practice remains extremely vulnerable to aggressive behavior on the part of insurance carriers and managed care companies whose profitability depends on reducing utilization of services.

The reason I am mentioning this here is that it has reminded me to encourage all our CPPNJ members to consider becoming involved in our respective professional organizations. The New Jersey Psychological Association (NJPA), one of the largest and most active state psychological associations in the country, has been very actively involved in efforts to protect patient privacy, and to advocate for the practice of psychotherapy in the state through legislative efforts, law suits against insurance companies, and public relations campaigns.

Most of you are already aware that the New Jersey Society for Clinical Social Work (NJSCSW) is co-sponsor of many of our public programs, helping CPPNJ to obtain continuing education accreditation for our members and other clinical social workers who attend our programs and workshops. NJSCSW is the organizational voice of clinical social workers in our state, likewise advocating for the value of psychotherapy through public information, legislative initiatives and advocacy efforts.

While most of our CPPNJ members are either social workers or psychologists, our membership also includes psychiatrists, nurse practitioners, marriage and family counselors, and other licensed mental health professionals, who also each have their own professional associations, each of which represents a large number of our colleagues whose primary identification is with the practice of psychotherapy.

I believe these all these state associations representing the different mental health professions are extremely important for psychoanalytic practitioners. For one thing, their membership is comprised mostly of practicing psychotherapists, unlike other, more academically-oriented organizations. They specifically seek to advance the interests and concerns of independent practitioners, and advocate for consumers of psychotherapy services, and so are our natural allies. I believe it is vitally important for psychoanalytic practitioners to participate in these professional associations to advocate from within for the particular values and aims of psychoanalytically-oriented practice. It is essential that psychoanalysts have a voice within these state organizations, to offer support where our goals are aligned, and also to speak for our particular interests.

I would encourage CPPNJ members not only to become members of these professional organizations, but also to consider seeking leadership roles within them. It is extremely important for our institute to have support and a voice in these professional organizations, to advocate for psychoanalytic values and practices, and through mutual support advance the interests of all independent practitioners.

CPPNJ does not exist in a vacuum. We are a relatively small organization, and on our own, we do not wield great political influence. We certainly might gain some political power by coordinating our own advocacy activities with other psychoanalytic organizations in the state where it is possible. But, the reality is, all of us practice under our respective mental health licenses, and it is therefore essential that each of us also participate in those professional organizations that already share at least some of our interests and goals, and that have greater resources and larger memberships than we. Because CPPNJ is made up of a diverse group of mental health professionals, we have something in turn to contribute by representing the possibility of multidisciplinary cooperation and solidarity on the basis of our shared clinical sensibilities and values - something which I believe will be extremely important in the coming years as we face turmoil and change within the larger field of health care.

In a 2000 New York Times interview, Sam Shepard observed, "The struggle with the land is finished...now the frontier is the computer, so it has become an internal thing.  Computers cause protracted dreaming about what might be, and the frontier everyone is seeking is now in the imagination...That means everything-relationships, families-has taken on a new dimension...We don't even need a family anymore; you can have an imaginary family."  (Weber, 2000 as in Gabbard, 2001).  Psychotherapy is hardly immune from the new technology.  Psychotherapists of various schools and modalities are grappling with what aspects of cyber-communication may be helpful to patients and also fall within ethical and legal treatment parameters.

Freud wrote to his established patients, but only adjunctively to the traditional person-to-person session, and most often when distance or forced interruptions, such as vacation, caused a disruption in the usual treatment.  Today, the boundary of the therapist's office has been stretched by new forms of communication such as e-mail, texting, Internet phone and videoconferencing.

Traditionally, little of the psychoanalytic therapist's personal life was revealed to his/her patients.  This was the practice of letting the transference develop without external intrusions, thereby allowing the patient to experience the therapist as a replication of childhood experiences.  Although judicious self-disclosure is used today by many relational therapists, revelations on the Internet are a different matter.  With the advent of social networks such as FaceBook, Twitter and LinkedIn, therapists now must be vigilant not only of what they post for friends and family, but also of the potential effect the postings could have on their patients.  As one patient recently said to me, "I don't want to know anything about you.  I just want you to be here for me."

It is interesting to see how creative therapists have incorporated new technology into their face-to-face work with patients, for example using technology as transitional space, and how patients have transformed their computer devices into transitional objects (Winnicott 1951).  The inter-relationship between humans and machines portrayed in the recent movie, Her, pushes the boundary of reality between humans and computers.  In the future practitioners will need to distinguish between acceptable and unacceptable usage of technology in their practices.  I will attempt to address some of these issues. 

Jonathan Shedler ( 2006, pg.13) wrote, "The goal of psychoanalytic psychotherapy is to help people become more mindful of their experience in the here and now."  In psychoanalytic psychotherapy, the patient and therapist work together in a metaphorical "potential" or "transitional" space, best described as a mixture of the literal and the symbolic, the real and yet unreal; a space where therapist and patient can "play" with feelings and ideas and, together, explore new ways of thinking.  Similar to the potential analytic space, computer technology is a mixture of the illusory and the factual, the actual and the inferred.  People use the computer, as they do psychotherapy, to gain knowledge about themselves and others, to acquire new perspectives, try on new feelings, educate themselves, fantasize, dream and to experiment with other, albeit temporary, personas. 

Use of e-mail presents the potential for confidentiality to be breached.  Most therapists don't use encrypted email, and once e-mail leaves the computer it travels through the Internet service provider, where it is retained.   As Gabbard observed, "the confidentiality of e-mails is roughly equivalent to the confidentiality of a postcard; after an e-mail is sent it does not disappear, but is traceable and identifiable." (2001, pg. 732)

A relevant issue to consider in cyber dyadic communications is the feelings that may be evoked in the therapist upon receiving sexually charged e-mails.  Gabbard wondered, "Was I transgressing a boundary by incorporating e-mail communication into analysis, or was I breaking new ground on the analytic frontier in a constructive and creative way?" (2001, pg. 733)

Computer devices can take on individual meanings.  For several years, my patient, Sally, communicated with her boyfriend through text messaging.  As one would expect, this kept the relationship stagnant at a safe yet increasingly frustrating distance, and Sally was able to maintain illusions about the relationship that were not in keeping with the reality.  In unpacking the text messages during our sessions, these illusions gave way to a more realistic understanding of the relationship.  Our sessions illuminated her disappointing childhood relationship with her mother and her unspoken longing for closeness, which had been unattainable.