Therapy

Cyborgs in a Pandemic

The sudden explosion of video-therapy.

Posted Jun 29, 2020

Now, in the midst of a pandemic, I can see how video-therapy affects my work as a psychiatrist. I see it play out in realtime. 

Actually, I’ve practiced video-therapy for years, but I never thought much about it. It was always at the margins – mostly where someone could not physically attend a session, or had moved out of town, or was from another area. I saw it as useful, occasionally, but nothing I’d want to practice full-time.

In a weird way, it evoked a sort of Twilight Zone of man-machine cyborgs that didn’t belong in the staid, traditional world of psychiatry.

But all that’s changed now.

Ever since the pandemic has made cyborgs of us all – in everything we do – video-therapy has become my modus operandi. It has, indeed, for most New York psychiatrists. So, I was interested to see Adam Gopnik’s opportune article (“The Empty Couch”) in The New Yorker, examining how the current crisis – with everyone sheltered in place – is reshaping psychiatric practice. 

For starters, Gopnik observed that video-therapy facilitates easier access to care and psychological services. True. But that’s also true of almost any non-invasive medical treatment. What interested me more about the article was the claim that some psychiatric patients might actually be better treated remotely. That seemed radical. We leak our feelings through our pores. We get the scent of someone in the room with us. We “feel” the concomitants of their presence. How could that translate to a screen with two talking heads? We’d each miss the body language.       

But I wanted to test Gopnik’s claim. So, I wondered what was therapeutic in psychotherapy. That is, what elements in a complex process actually make it work? When you’ve practiced for over 25 years, as I have, you tend to see the process holistically and never stop to analyze whether any specific element – including physical presence – is responsible for the empathy and understanding that lead to recovery. 

My background was as a neo-Freudian. Intense, frequent psychoanalytic treatments were the “gold standard”; anything else would not expose a patient’s unconscious conflicts and underlying issues. In fact, this is still the prevailing view at traditional psychoanalytic institutes. So how would diluting the intensity by eliminating the in-person connection increase the therapeutic effect? It sounded like a paradox.    

Admittedly, I had treated patients in Beijing, Hong Kong, and Dubai without meeting them in person. We had even worked through significant psychological issues. But was the treatment better? 

I thought some more about the type of connection that we achieve through a screen. Sometimes treatment can be more focused than is possible in an office visit; we get to the heart of an issue more quickly; we lock eyes (the windows and my artworks are out of bounds), and the patient can’t, perhaps, as freely associate. This creates a more interpersonal, less intrapsychic experience. From a psychiatrist’s perspective, what you see is more nearly equivalent to what you actually get. Less wandering down byways that, years later, may turn out to be productive. So, after some reflection, I granted Gopnik the benefit of the doubt.  

At least, as a thought experiment. What about with a real patient?

As a case in point, I offer my patient Sam. I spoke with Sam remotely today. He is (or was) a successful businessman in his 50s, but his company was clobbered by the pandemic. He’d lost millions. Then his business partner had defrauded him. He felt devastated.  

He felt the way he did back in prep school, when the wealthy kids made him feel self-conscious. He was that same outsider again, he said. “I feel like people are looking at me, laughing. Could I have done something differently?” I wanted to reassure him but was concerned (notwithstanding my provisional concession to Gopnik) that the distance between us was an emotional barrier. I imagined how we would have talked, mano a mano, had we been seated across from each other. But instead, I ticked off his accomplishments; I suggested that his self-worth should not reflect his net worth; it sounded rote. It was cliché. We both knew it.

But then the mood quickly shifted. It was like a phase change – ice to water. Sam’s focus narrowed from generalized despair to a specific recollection of his life as a young man. He recognized that the intrusion of memory into the present was exacerbating his despair. 

He talked about how his father had sacrificed so much for so long and, in the end, had so little to show for it. “He was left with a five and dime store, and now I’m just like him.” He recalled how his father would travel weekends for a second job and how he was still in his own eyes just a hapless loser. “Maybe I’ll start working for Uber Eats. I hear it’s a growth industry.” You could hear the self-mockery. You could hear it through what Sam always wished he had said to his father. In that moment, Sam stood in for his younger self, jabbing at a father who left him vulnerable to schoolboys. He was standing in for his prep school classmates, re-enacting their silent taunts.  

I had worked with Sam for several years, and I had never seen him so pitiless towards himself. He’d always had a sense of irony, but usually, this sense was tinged with the comedic – more pratfalls than tumbles into darkness. But this time he was dead serious. He drew out the connection between a grim past – at home, at school – and his current, grim sense of drawing the short straw.

But here is where I am going with this. “You know,” he said, “it’s because your attempt to reassure me fell flat that I’ve had to figure all this out for myself.” He said he didn’t think he could have made the connection between himself, his father, and his current state of mind if we’d been talking in my office.  “I might have appreciated your attempt, and then the moment would have passed.”  

What happened is that the video-therapy concentrated Sam’s mind. When you stare at someone, and everything else falls away, you’re actually almost all mind. Your mind moves easily, back and forth through your personal history and its demands on the present. You take control of your mind. That’s key. Rather than allowing it to wander, you force it into channels that can run very deep. Like the businessman that he was, Sam took charge. For a short while, I faded away. It’s like I wasn’t there, even though he was looking me straight in the eye. He became his own facilitator.

Ultimately, he told me what I needed to know so that – together, finally – we could work out the circuitry of his current despair. This might have happened over weeks in my office, but here it happened virtually in a flash. 

I think that when you stare into someone’s eyes, it can also drive you inwards. That’s what Gopnik understood, albeit implicitly.    

So, while I would say that the jury is still out, I have to acknowledge that Gopnik is on to something that could signal a paradigm shift. Video-therapy does not mean that “therapy,” now paired with “video,” diminishes the value of personal contact. Rather, it means that the process of therapy may be altered as we apply the capabilities of its video component. If my experience with Sam is any indication, we may be surprised by how quickly and intensely patients respond.