Many of us have not gone back to in-person sessions even though the Covid epidemic has passed. Before March 2020 I was firmly convinced that telephone sessions were better than skipping sessions, but not as valuable as in-person sessions. I only agreed to telephone sessions when patients went on long business trips or had some other compelling reason that made them unable to come in person. But beginning in March 2020 my practice transformed — all phone (or in a few cases video) sessions. After two years of living in my “weekend” house, I sold my office in New York and accepted the fact that my practice was going to be entirely by telephone. I use video calls for new patients (for a determined period) and for couples, but telephone sessions for everyone else.
Since my “conversion,” I have thought a lot about the pros and cons of telephone vs. in-person treatment. In the newest volume of The Psychoanalytic Review, Carl Jacobs writes, “…telephony is so much more preferable to video. Since the time of its origin, psychoanalysis has been based predominantly on listening: The use of the couch is more easily replicated by telephone.” (March, 2024). I agree that for some patients, speaking on the phone makes it easier to talk about difficult subjects and may feel more intimate than video or even in-person treatment. However, phone sessions and video sessions make it impossible for the analyst to recognize non-verbal enactments.
John slams the door each time he enters my office; Hal has body odor; Janet brings coffee to her session and spills it in the waiting room; Barbara puts her feet up when she sits on my couch without taking off her shoes. In all these cases, analysis of the meaning of the behavior led to fruitful discussions of their unconscious meaning. This was particularly true with Sharon, who physically enacted what she could not tell me or maybe even admit to herself.
“Are you aware of how you're sitting?” I asked.
Sharon immediately put her knees together.
“What are you talking about? What are you saying? I’m sorry. You hate me. You think I’m bad. What are you saying? You want me to leave?”
“I don’t hate you,” I said. “I don’t want you to leave. You were sitting with your crotch exposed to me and I think that has some meaning. Don’t you?”
“I'm sorry. I like you and I respect you. I don’t know what you’re saying,” she cried. “You think I’m bad. I’m sorry. You want me to leave.”
“I know you like me and respect me, and I don’t want you to leave,” I said. I leaned forward in my chair. “I don’t think you are bad. You don’t need to apologize. I just think that sitting like that means you have some feelings about yourself and about me that we need to understand.”
“I’m sorry. Sitting like that doesn’t mean anything. I just don’t think it matters how I sit.”
“You mean it doesn’t matter if your crotch is exposed or not?” I asked.
“I just don’t feel like a sexual person. I don’t feel like a woman. Look how I dress. Look how I take care of myself. I just don’t feel like a sexual person that’s why it doesn’t matter how I sit.”
“You mean you feel like there’s nothing between your legs?”
“That’s right. What’s between my legs is dirty and smelly and bad and disgusting. You don’t want to see it.”
“So, you think that I am pointing out how you’re sitting,” I said, “because I feel your vagina is bad and smelly and disgusting.”
“I offended you. I’m sorry. I won’t do it again. Don’t worry about it.”
“You didn’t offend me. But I think exposing yourself is a way of telling me something.”
“You know you’re inappropriate sometimes? I can’t believe you said that to me. Who would say such a thing? I don't know anyone who would say such a thing.”
“You mean you would rather I act like your mother and make believe that there’s nothing between your legs or that it’s too disgusting to talk about?”
“Maybe it’s like my leg. I don't want you to see that I have a disfigured leg. I want you to say you can’t tell I have it. But I also don’t think I have anything. I am completely out of touch with my body (crying). I don’t feel connected to it. I can’t touch myself still. I don't feel like a woman. I don’t really have breasts. Sometimes I don’t even bother to wear a bra.”
“What about underpants?”
“What do you think is wrong with me? Do you think I don’t wear underpants? Of course, I wear underpants.”
“If you don’t feel you need to wear a bra because you don’t feel you have breasts, I wondered if you wear underpants because you feel you don’t have a vagina or clitoris.”
“Of course, I wear underpants. What do you think is wrong with me? How could you say that? I can’t believe it. You must think I’m disgusting.”
[She got up and walked out of the office. My heart was pounding. I had at first doubted what I was seeing and went back and forth in my mind about whether I was seeing her genitals. I told myself it could not be true. It was not possible. I had never experienced such an explicitly sexual enactment with a patient. But finally, I knew what I was seeing and felt that if I ignored it, I would be sending her the message that she wasn’t a woman, that there was nothing between her legs. On the other hand, if I said something, I risked overwhelming her and pushing her out of the treatment. I decided I had to say something to her; I had to say the unspeakable, but I wasn’t sure if she would come back.]
[When Sharon did come back for the next session, she was angry for the first few minutes. But then she told me that after the session, she remembered her mother sitting in the living room on the couch with her legs spread and touching herself.]
“You mean your mother was masturbating in front of you,” I said.
“Yes. She did it in front of my brother too. I wasn’t sure what she was doing. I asked her to stop, but she said she wasn’t doing anything.”
[Her mother overstimulated Sharon and then denied it. Sharon was forced to develop ways of coping with her mother’s abuse — being confused about reality was a defense against unbearable anxiety.]
File under: Therapy & Technology, Online Therapy
Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.
Since my “conversion,” I have thought a lot about the pros and cons of telephone vs. in-person treatment. In the newest volume of The Psychoanalytic Review, Carl Jacobs writes, “…telephony is so much more preferable to video. Since the time of its origin, psychoanalysis has been based predominantly on listening: The use of the couch is more easily replicated by telephone.” (March, 2024). I agree that for some patients, speaking on the phone makes it easier to talk about difficult subjects and may feel more intimate than video or even in-person treatment. However, phone sessions and video sessions make it impossible for the analyst to recognize non-verbal enactments.
John slams the door each time he enters my office; Hal has body odor; Janet brings coffee to her session and spills it in the waiting room; Barbara puts her feet up when she sits on my couch without taking off her shoes. In all these cases, analysis of the meaning of the behavior led to fruitful discussions of their unconscious meaning. This was particularly true with Sharon, who physically enacted what she could not tell me or maybe even admit to herself.
A Revealing Therapeutic Interchange
[Therapist’s thoughts]: I am aware that Sharon’s crotch is in full view. She does this often when she is wearing a skirt. I am trying not to look at her crotch while she is talking to me, but I have the impression that she is not wearing underpants. I think to myself that perhaps she is just wearing dark underpants. I start to question myself. Am I really seeing her genitals? Yes, I am. How should I handle it? If I ignore her exposing herself to me, I will be doing what her mother did — acting as if she is not a female with genitals. On the other hand, I know that however I say it to her, she will be mortified and furious at me. In the past, I felt the mortification would be too much for her, but this time I feel this is much more directly sexual than her sitting this way in the past.“Are you aware of how you're sitting?” I asked.
Sharon immediately put her knees together.
“What are you talking about? What are you saying? I’m sorry. You hate me. You think I’m bad. What are you saying? You want me to leave?”
“I don’t hate you,” I said. “I don’t want you to leave. You were sitting with your crotch exposed to me and I think that has some meaning. Don’t you?”
“I'm sorry. I like you and I respect you. I don’t know what you’re saying,” she cried. “You think I’m bad. I’m sorry. You want me to leave.”
“I know you like me and respect me, and I don’t want you to leave,” I said. I leaned forward in my chair. “I don’t think you are bad. You don’t need to apologize. I just think that sitting like that means you have some feelings about yourself and about me that we need to understand.”
“I’m sorry. Sitting like that doesn’t mean anything. I just don’t think it matters how I sit.”
“You mean it doesn’t matter if your crotch is exposed or not?” I asked.
“I just don’t feel like a sexual person. I don’t feel like a woman. Look how I dress. Look how I take care of myself. I just don’t feel like a sexual person that’s why it doesn’t matter how I sit.”
“You mean you feel like there’s nothing between your legs?”
“That’s right. What’s between my legs is dirty and smelly and bad and disgusting. You don’t want to see it.”
“So, you think that I am pointing out how you’re sitting,” I said, “because I feel your vagina is bad and smelly and disgusting.”
“I offended you. I’m sorry. I won’t do it again. Don’t worry about it.”
“You didn’t offend me. But I think exposing yourself is a way of telling me something.”
“You know you’re inappropriate sometimes? I can’t believe you said that to me. Who would say such a thing? I don't know anyone who would say such a thing.”
“You mean you would rather I act like your mother and make believe that there’s nothing between your legs or that it’s too disgusting to talk about?”
“Maybe it’s like my leg. I don't want you to see that I have a disfigured leg. I want you to say you can’t tell I have it. But I also don’t think I have anything. I am completely out of touch with my body (crying). I don’t feel connected to it. I can’t touch myself still. I don't feel like a woman. I don’t really have breasts. Sometimes I don’t even bother to wear a bra.”
“What about underpants?”
“What do you think is wrong with me? Do you think I don’t wear underpants? Of course, I wear underpants.”
“If you don’t feel you need to wear a bra because you don’t feel you have breasts, I wondered if you wear underpants because you feel you don’t have a vagina or clitoris.”
“Of course, I wear underpants. What do you think is wrong with me? How could you say that? I can’t believe it. You must think I’m disgusting.”
[She got up and walked out of the office. My heart was pounding. I had at first doubted what I was seeing and went back and forth in my mind about whether I was seeing her genitals. I told myself it could not be true. It was not possible. I had never experienced such an explicitly sexual enactment with a patient. But finally, I knew what I was seeing and felt that if I ignored it, I would be sending her the message that she wasn’t a woman, that there was nothing between her legs. On the other hand, if I said something, I risked overwhelming her and pushing her out of the treatment. I decided I had to say something to her; I had to say the unspeakable, but I wasn’t sure if she would come back.]
[When Sharon did come back for the next session, she was angry for the first few minutes. But then she told me that after the session, she remembered her mother sitting in the living room on the couch with her legs spread and touching herself.]
“You mean your mother was masturbating in front of you,” I said.
“Yes. She did it in front of my brother too. I wasn’t sure what she was doing. I asked her to stop, but she said she wasn’t doing anything.”
[Her mother overstimulated Sharon and then denied it. Sharon was forced to develop ways of coping with her mother’s abuse — being confused about reality was a defense against unbearable anxiety.]
***
Sharon’s traumatic childhood experience would not have been unearthed if I was talking to her on the telephone or video (which is face-to-face). On the phone or on video, she would not have been able to engender in me the same confusion, self-doubt, anxiety, and denial that she experienced as a child; she would not have been able to communicate the unspeakable truth. Telephone sessions may be useful for many patients, but for those who enact rather than verbalize their early experiences, it is not optimal.
Questions for Thought and Discussion
What are your impressions about this author’s clinical approach with this client?
Might you have done or said something different under these circumstances?
How do you address uncomfortable situations like these in your practice?
File under: Therapy & Technology, Online Therapy