Dear Colleague, 

Because some people had difficulty accessing Estelle Krumholz's article in our May e-newsletter, we are resending it in a format that should be easier to view.

We hope you enjoy her article.

Sincerely,
Mary Lantz, Editor  

 

The New Frontier: Therapists and Patients in Cyberspace 
By Estelle Krumholz, MSW, LCSW
 

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.

 

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