Does online therapy work? Even with a four-year-old banging on the door, it's better than nothing

There are challenges to long-distance therapy. But it also allows sessions to take place from anywhere
October 9, 2017

Walking the dogs with a psychoanalyst on Hampstead Heath (I know, I know). “But what if the connection fails?” he asked, and I admitted that it quite often does. “Do you interpret it?” he wanted to know. We both laughed, but sometimes I do. I say; “It’s quite hard for us to connect to each other today.” More laughter, muddy black labradors, Alastair Campbell on his run. Melvyn Bragg on his walk. Autumn leaves.

We were talking about Skype, the highly unorthodox medium via which I now see a couple of my patients. Years ago, I was in a supervision group at that hospital in Kings Cross that used to be the Hospital for Tropical Diseases (my dad once tried to check himself in with self-diagnosed cholera on return from covering conflict in Southern Africa and was told to go home-—he’d been drinking too much coffee, smoking too many cigarettes and not eating enough). Someone in my group was seeing an acutely agoraphobic patient via Skype. There were sharp intakes of breath, pleas to be open-minded from the group leader, fumbling embarrassment from the transgressive therapist. But her weekly reports were pretty much the same as those of the rest of ours, transference included.

Not picking up on the transference and countertransference is the biggest potential problem with long-distance therapy. So, with apologies to everyone in the field, this means the unspoken relationship between patient and therapist, the things projected and potentially introjected. Very simplistically, aspects of the transference might be revealed by the question: How does the patient make me feel? If a patient is unconsciously angry the therapist might start to feel angry. The therapist will hopefully say, “I think you feel angry,” rather than acting out and expressing anger towards the patient.

So, when one of my patients moved to a remote area in the Middle East where English-speaking psychotherapy is not an option, I suggested we continue via Skype. The sometimes unbearable intimacy of being in a small room with someone experiencing extreme emotions is, as you’d expect, somewhat lost. It isn’t as intimate as face-to-face therapy, it just isn’t. Silences can be just that—silences. It’s far harder to catch the meaning behind a silence through a screen. This, in my case, results in wordier sessions. I cut in sooner with a “What are you thinking about?” or a “Where are you?” (my own analyst’s favourite silence-ender.) Nonetheless, those spooky moments where you hear the name they’re about to say just before they say it, where you have the same thought at the same time, absolutely still happen.

I often used to cry all the way home in the car from my analyst’s house (you could argue that anyone stuck in traffic in Willesden would be weepy…)—the journey to and from therapy is an important processing space. But, yesterday, I saw a patient whose four-year-old started banging on the door 10 minutes before the end of our session. She was going straight back on duty as soon as she closed the laptop. Another patient often sees me from the office and might be rushing to a meeting afterwards, torn open and not yet put back together again. For that reason, it feels more important on Skype not to end a session with a searing interpretation that will leave a patient feeling shredded (not that I’m claiming to be a huge mine of searingly brilliant interpretations.)

But all this leads me to the very important upside of Skype therapy—people run away less. Nobody always wants to come for their therapy, everybody wants to leave when it gets difficult and it’s easy to use the excuse of moving abroad, having too much work, or not being able to find anyone to look after the kids as a reason to stop. Skype means it’s always possible to have your session, as long as there’s wifi. I’ve had someone do a session with a child colouring on their lap, another patient did one from the corner of an airport lounge.

People in the business talk and write a lot about “the Space,” the physical and mental space in which therapy happens. It is that space to think and feel that is thought to be curative and it’s fascinating that despite the screen and the distance, the same psychological space still arises. However, the main argument, in favour of Skype sessions is this—it is a lot better than nothing.