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Review: Empathy and Mental Health by Arthur J. Clark
Empathy and Mental Health: An Integral Model for Developing Therapeutic Skills in Counseling and Psychotherapy. London: Routledge 2022 Electronic Version
As a young man, Arthur J. Clark heard Carl Rogers speak and was inspired to devote his life’s work to applying empathy in education, counseling, and talk therapy. This book is the distillation of years of experience and learning, and we, the readers, are enriched and even enlightened in this original synthesis of existing ideas on empathy. It is fully buzz word compliant, diligently calls out the limitations and risks of empathy, and guides the readers in expanding their empathy to make a difference in overcoming suffering and mental illness. It takes a lot of empathy to produce a book on empathy, and empathy is evident in abundance in Clark’s work.
As noted, Clark’s academic background is in education, as was Carl Rogers’, but the reader soon discovers Clarks’ work with empathy to be generously informed by Freud, Ferenczi, and Adlerian psychoanalysis. Thus Clark quotes [Alfred] Adler (1927): “Empathy occurs in the moment one individual speaks with another. It is impossible to understand another individual if it is impossible at the same time to identify oneself with him” (Clark: 20). At this same time this reviewer was enlivened by the application of distinctions to be found in the Self Psychology of Heinz Kohut and the latter’s colleagues Michael Basch and Arnold Goldberg. This brilliant traversal of the practice and conceptual landscape of empathy inspired Clark’s life work, and is on display here.
The book is filled with short segments of transcripts of encounters between counselor/therapist and client. To the point that empathy is much broader than reflecting feeling and meanings, examples are provided of empathic encouragement, empathic being in the here and now (immediacy), empathic silence, empathic self-disclosure, empathic confrontation, empathic reframing, empathic cognitive restricting, empathic interpretation. Clark’s work with empathic reframing, cognitive restructuring, and interpretation are particularly useful (Clark: 105 – 106).
“Empathy” is not so much a substantive as a modifier – a manner of being that applies across a diversity of ways of relating to the other individual. (It is a further question, not addressed by Clark, as to the status of these vignettes. Are they disguised, permissioned, ideal types, some combination thereof? Just curious. In any case, they work well and remind me of M. F. Basch’s vignettes in the latter’s Doing Psychotherapy.)
Clark makes reference to the celebrated video (e.g., widely available on Youtube) of Carl Rogers, interviewing the real-world patient “Gloria” about her relationship with her nine-year-old daughter “Pammy.” Rogers’ empathic listening skillfully turns the focus from Gloria’s presenting dilemma of how much information about sex to share with her inquisitive nine-year-old daughter, Pammy, into a willingness on the part of Gloria’s to call out her own blind spots and conflicts over sex. Rogers’ empathic responsiveness shows the way for Gloria to recapture her own integrity around adult sexuality so that she can provide Pammy with the appropriate sex education the child needs, regardless of the details that may be relevant only to the adults. And Rogers does this in about twenty minutes, not months of therapy.
At this point, it is useful to give Rogers’ definition of empathy (p. 11): “To perceive the internal frame of reference of another with accuracy and with the emotional components and meanings which pertain thereto as if one were the person, but without ever losing the ‘as if’ condition.” Rogers was definite about excluding the perspectives of the practitioner in conceptualizing empathy in his person-centered approach to therapy. In this regard, he stated, “For the time being you lay aside the views and values you hold for yourself in order to enter another’s world without prejudice.”
Clark’s integration of the diversity of approaches to empathy in history, theory, and practice distinguishes subjective, object and interpersonal empathy: “Subjective empathy encompasses a practitioner’s internal capacities of identification, imagination, intuition, embodiment that resonate through treatment interactions with a client and empathically reflect the individual’s experiencing. Objective empathy pertains to the deliberate use of a therapist’s conceptual knowledge and data-informed reasoning in the service of empathically understanding a client in a relational climate. Interpersonal empathy relates to comprehending and conveying an awareness of a client’s phenomenological experiencing and pursuing constructive and purposeful change through the application of a range of interventions” (Clark: xiv).
Clark started out as a school counselor and he gives the example of the student who comes in and says “I hate school!” The reflection is proposed to be something like “You are feeling angry about school.” This demonstrates just how important the tone in which a statement is made can be. This could indeed be an angry statement, which takes “hate” is a literal way. However, it could also be an expression of contempt, disgust, cynicism, resignation, sadness, or even fear (say, since the student is being bullied). The empathy is precisely to acknowledge that the listener is far from certain that he does knows what is going on with the student and to ask for more data. “Sounds like you are struggling with school – can you say more about that?”
Not afraid of controversy or tough topics, Clark’s contribution is thick with quotations from the founding father of psychoanalysis – Adler and Freud and the literature Freud has been reading such as Theodor Lipps, to whom we owe the popularization in Freud’s time of the term “empathy [Einfühlung]. The subsequent generation of ego psychoanalysts is also well represented Ralph Greenson, T. Reik, Jacob Arlow (and Beres).
Clark credits and recruits Ralph Greenson’s distinction of the therapist’s inner working model of the patient and uses it to enrich Rogers’ contribution to empathic understanding. “As empathic understandings evolve through therapeutic exchanges and assessment interactions, a model of an individual emerges that becomes increasingly refined and expansive. In turn, by ways of empathically knowing a client, the framework facilitates sound treatment interventions through the engagement of interpersonal empathy” (Clark: 88). Note that Clark aligns with the view that the countertransference is distorting/pathological as opposed to the total response of the therapist. There are many tips and techniques guiding the therapist diligently to monitor and control the countertransference neurosis.
Since this is not a softball review, I note some issues for productive debate. For example, if Clark had allowed that countertransference included the therapist’s entire reaction to the client, including personal reactions which are not necessarily conflicted or neurotic (on the part of the therapist), then Clark would have been constrained to spend more ink on his own individual responses, empathic and otherwise. Such disclosure, which Clark otherwise separately validates as appropriate in context (and if not this context, then which?), would have enriched a text which otherwise reads like a textbook (and perhaps that was the editorial and marketing guidance).
Also useful is the therapist’s being sensitive to cultural differences and dynamics. In a brief transcript of an interaction between a privileged white school counselor and an African American 8th grader attending the college prep private school (Clark: 42), we are supposed to see objective cross-cultural empathy based on the counselor’s reading of some articles (not specified) on cultural differences.
By all means, read up on cultural differences. However, I just see a rigorous and critical empathy (my term, not Clark’s), plain and simple. The counselor “gets it.” The student is afraid of being seriously injured or even killed by the criminal element in his neighborhood as he waits for the school bus. Is this breakdown of policing in the inner city really in the cultural article? The counselor also “gets it” that the student’s feelings are hurt by being laughed at by his more privileged classmates because his mom is a house cleaner rather than an executive or doctor or lawyer. It is the counselor’s empathic response based on her empathic understanding of the student’s specific fear and hurt feelings that enables the student to deescalate from his problematic acting out. Even though, like most 8th graders, the student would be the last to admit he has been emotionally “touched,” he was. Thus, Clark’s empathy shines through in spite of his style-deadening need to accommodate behavioral protocols, evidence-based everything, and the plodding style of delivery consistent with training in schools of professional social work and psychology.
“Objective empathy” may seem like “jumbo shrimp,” an oxymoron. Nor is it clear how dream work, with which Clark productively engages, falls into the “objective” rubric. Yet it is a highly positive feature that Clark emphasizes and explores in detail the value of dream work.
Let one’s empathy be informed by the context: “Consider, for instance, what are the daily struggles like for a client who meets the diagnostic criteria for a bipolar disorder or attention deficit [. . . .] When giving consideration to such challenges through a framework of empathic understanding, a practitioner calls upon reputable data and a spectrum of work with individuals from diverse backgrounds in order to generate a more inclusive and accurate way of knowing a client” (Clark: 35).
And yet this precisely misses the individual who is superficially described according to labels, but has his own experience of bipolar or attention deficit. Empathy is precisely the anti-essentialist dimension, the dimension that is so pervasive in psychiatry and schools of professional psychology that replace struggling humanity with “You meet criteria for – [insert label].”
While Kohut is properly quoted by Clark as one of the innovators in empathy and Kohut’s concise definition glossing empathy as “vicarious introspection” is acknowledged, Kohut’s other definition of empathy as a method of data gathering about the other individual is overlooked. However, it aligns nicely with Clark’s description of “objective empathy.” Maybe my close reading missed something but why not just say “taking the other person’s perspective” is “objective empathy” as opposed to vicarious introspection (“subjective empathy”)?
The subtitle promises “An integrative model for developing therapeutic skills [. . . ]” Clark substantiates the need for work in critiquing all those training program that model the skill of repeating back to the client words similar to those the client expressed. “In a meta-analysis of direct empathy training, Lam et al. (2011) found that the majority of 29 studies did not clearly conceptualize or define empathy, some did not describe training delivery methods, and almost all of the initiatives failed to present evidence demonstrating individuals’ propensity to behave more empathically after training” (Clark: 140). Clark’s discussion of reframing, cognitive restructuring, and empathic interpretation are relevant and useful in overcoming what amount to a scandal in psychotherapy training.
What Clark is trying to say is this: You think you are being empathic. Think again. A rigorous and critical empathy (my phrase, not Clark’s) is skeptical about its own empathy. That does not mean being dismissive either of one’s own empathy or the struggle of the other person. It means being rigorous and critical. Empathy is made to shine in the refiner’s fire of self-criticism and a radical inquiry into one’s own blind spots.
Clark does not escape unscathed from the behavioral and observation protocol dead end. The reader will seek in vain for self-criticism or inquiry into Clark’s own blind spots – instead the reader is awash in the extensive behavioral, cognitive behavioral therapy (CBT) attempts, albeit empathically deployed, to capture therapeutic encounters in a behaviorally observable or reportable protocol. Nor I am saying there is anything wrong with that as such. Yet might not the behavioral and observation protocol swamp precisely be the blind spot where the self-deception lives against which Rogers frequently denounces? To gather the honey of self-knowledge and empathic understanding one must risk the stings of distortion and disguise.
Clark’s would be a different work entirely if he explored the college of hard knocks in which he forged the empathic integration. He is trying to make what is largely an artistic practice into a rule-governed scientific algorithm. It is worth a try and the reader must judge the extent to which Clark succeeds. Spending a lifetime preparing articles for peer-reviewed publications in education, psychology, etc., does not generally bring life and vitality to one’s practice, manner of engagement, or writing style. However, Clark’s richness of material, wealth of distinctions related to empathy, and organizing virtually every aspect of empathic research and published references goes a long way towards compensating for Clark’s work not necessarily being a “page turner.” Clark’s writing reminds the reader more of the Diagnostic and Statical Manual (DSM) – Ouch! – more than (for example) of D. W. Winnicot, Christopher Bollas, Arnold Goldberg, Freud, who was an expert stylist (granted much is lost in translation), or even Carl Rogers himself.
Thus, Clark’s integrated approach calls for “a diagnosis [as from the DSM] that represents the lived experience of the individual.” Agree. Clark gives an example where the therapist is interviewing Omar who has low energy, lethargy, lack of motivation, and hopelessness about the future. The diagnosis encapsulates and integrates a lot of Omar’s experience, and, though Clark does not say so, Omar may even be relieved to hear/learn that he (Omar) is not to blame for his disordered emotions (“major depression”); and Omar should stop making a bad situation worse by negative self-talk, verbally “beating himself up” in his own mind. The treatment consists in getting Omar to do precisely what the depressed person is least inclined to do – take action in spite of being unmotivated. If one is waiting to be motivated, absent a miracle, it is going to be a long wait. Maybe the empathic response is precisely saying this to the client, acknowledging how hard it is (and may continue to be for a while) to get into action on one’s own behalf.
This is all well and good. However, narrowly or expansively empathy is defined it is the anti-DSM (diagnostic and statistical manual). The DSM has many uses, especially in aligning terminology such that the community is talking about the same set of criteria when it uses the word “generalized anxiety disorder.” It also has uses in requesting insurance reimbursements. In short, there is nothing wrong with the DSM-5 (2013) or any version – but there is something missing – empathy. In the case of empathy, the recommendation is to relate to the struggling human being who presents himself in therapy, not to a diagnostic label.
Thus, Clark makes the case in his own terms: “From a humanistic perspective with central tenets focusing on respect for the individuality and uniqueness of a person, employing the DSM to categorize clients through a labeling procedure is thought to impede the growth of authentic relationships and empathic understandings of a deeper nature. In this regard, in a human encounter, perceiving a client through categorical frames of reference and symptomatic functioning hinders an attunement with the individual’s lived experiences and personal meanings. Moreover, applying a label to a client possibly influences a practitioner to shape preconceptions that are objectifying and forecloses a mutual and open-minded exploration of the contextual existence of the individual” (Clark: 27).
Though Clark does not say so, almost every major mental illness involves a breakdown of empathy. The patient experience isolation. “No one ‘gets’ me.” “No one understands what I am going through.” This is the case with most mood disorders, thought disorders, as well as those disorders typically described as “disorders of empathy” such as some versions of autism spectrum and anti-social personality disorders.
One matter of editing detail may be noted, a consistent misspelling of the name of celebrated primate researcher, philosopher, and empathy scholar Frans de Waal. There are no “Walls” in de Waal’s name – or in his empathy! We will charge this wordo to the editors who otherwise perform an admirable job.
Returning to a positive register, one of the most important takeaways from engaging with Clark’s work is that short therapy in which empathy is the driving force is powerful and effective. Clark does not specify the elapsed treatment in most cases, but I did not find one that was explicitly called out as being longer than fourteen weeks.
The emphasis is on the use of empathy in relatively brief psychotherapy – which is a powerful and positive approach that pushes back against the assertion that one needs cognitive behavioral therapy for relatively time-constrained encounters. Empathy produces quick results when skillfully applied. It is true that one of the great empathy innovators, Heinz Kohut, had some famous long and multi-year psychoanalyses; but these individuals were significantly more disturbed than Clark’s example of Anna, whose presenting behaviors were largely social awkwardness.
A strong point of Clark’s work is his debunking of the caricature of Rogers definition of empathy (and indeed of empathy itself) as merely reflecting (i.e., repeating) back to the speaker the words that the speaker has said to the listener. There is nothing wrong as such with reflecting what the other person has said, especially if the statement is relevant or well expressed. However, the mere words are pointers to the other person’s experience and are not reducible to the mere words. This is not a mere behavioral skill of reflecting back language, but a “being with” the other in the complexity and depth of the other’s experience as refined in the therapist’s own experience, and that is something one can best learn in years of one’s own dynamic therapy. Additional processing of the other person’s experience is encapsulated by and captured in the other person’s words, but not reducible to the words. The aspects of empathic responsiveness, embodiment, acknowledgement, recognition, encouragement, immediacy, possibility, clarification, and validation of the other’s experience form and inform the empathic response and the reply to the other.
A rumor of empathy is no rumor in the case of Clark’s work – empathy lives in his contribution to integrating the diverse and varied aspects of empathy.
Edwin Rutsch interviews the author Arthur J. Clark:
(c) Lou Agosta, PhD and the Chicago Empathy Project
Empathy versus bullying: Part 2: Online bullying and what to do about it
Listen as a podcast on Spotify (via Anchor): https://anchor.fm/lou-agosta-phd/episodes/Empathy-versus-bullying-Part-2-Online-bullying-and-what-to-do-about-it-e17hj9j
The cyber bully: The rule of thumb is that whatever a person does in life offline, the person does online, too. Whatever the person does in the non-electronic world of personal encounters, the person also does online in social networking. Therefore, people who are mean in person, will be mean online. People who are cruel in person will be cruel online. However, the impersonality of the online milieu can amplify the tendency. The lack of context of the online environment can intensify the upset and impact all around.
Prior to social media such as Facebook, bullied kids could find a haven from a heartless world at home. Now the kid who is the target of the bullying, having survived the day at school, survived the ride home on the bus, gets home, naively turns on the computer and (wham!) experiences additional, hurtful boundary violations. The unsophisticated kid, who does not know when to “power down” and hit the off button for her or his own mental health, can become quasi-hypnotically obsessed with checking and rechecking for devaluing comments.
No, the mere passage of time does not cause insulting online comments to go away. Social media make it possible for people to “pile on” and accumulate more “likes” for a hurtful remark. Furthermore, cyber-bullying can be perpetrated relatively anonymously with pseudonyms.
Fake accounts on Google or Facebook eventually get unmasked and deleted; but it takes time; and new fakes seem to spring up just as fast as the old ones get identified and deleted. If giant corporations, supposedly sophisticated politicians and business persons, major law enforcement organizations, the US government, and the US population at large, can be “faked out” by faked identities and misleading “news,” pity the middle school kid in the face of anonymous, hurtful language directed at her or him.
As the latest debunking of the pretensions of Facebook unfolds on the front page of the Wall Street Journal [no progressive rag, that publication!], the susceptibility of online platforms to fake everything is taking its place among the unintended (and deeply disturbing) consequences of technology that will live on.[i]
Figuring out who is doing what to whom online and when they are doing it requires a forensic inquiry of significant subtlety, time, and effort. School administrators are flummoxed, because the bullying is initiated off-campus.
How is it then that the school resources, already stretched thin, now must be marshaled to establish responsibility for policing such misbehavior? The target of the bullying may be asked to demonstrate that the abuse is affecting her or his school work. More blaming the victim?
Of course bullying is not a logical process. An ultimatum from a bully to her or his minion is itself a form of bullying: Call some prepubertal girl a “slut” or we won’t be friends anymore. Hello? If this were a logical process, then the would-be minion would already know that the friendship ended with the very request, since friendship is not conditional on hurtful (and unethical) words or behavior.
To many kids “friendship” means something quite different than “share wholesome experiences.” It means laugh at my jokes even if they are not funny, say my hair looks great even if it doesn’t, sit with me in the cafeteria at lunch, and do not flirt with the boy in whom I am interested this week. These young people do not know that book Nine of Aristotle’s Ethics is on friendship. The expectation that such an explanation would elicit any response from the young person other than eye rolling is doubtful. Still, it may be worth a try.
Given that cyber bullying has exploded as a form of online pathology, let us take a look at proper online conduct even in the absence of bullying.
The genie is out of the bottle—the genie is social networking
Social networking is not going away. Humans invented computers and smart interfaces. Let’s be smart is using them. When the child is interacting through Internet video with a family member living on another continent, then such an interaction is a boundary expanding and richly rewarding experience. When a parent and child are playing a game together using a computer screen, the benefit is in the parent-child interaction as such. The rich computer graphics are a bonus.
The paradox is the anti-social nature of social networking. The computer screen isolates the person even as the person is trying to connect. The contrary is also the case. The screen connects the person when the person wants to be alone, rudely announcing an incoming message by beeping, demanding one’s attention. Sometimes the screen brings out the anti-social tendencies instead of the pro-social ones, enabling one to be inauthentic, hiding behind a false self. [ii]
It is perhaps a symptom of the broader issue that the online world even calls forth innovations in punishment. Taken to its logical conclusion, the savvy, harried parent steals a march on the technology. The ultimate method of grounding? Take away the child’s electricity, thereby having a “time out” on the use of electronic devices. However, during the time out do something positive. Read a book! Play a board game with your sister. If the latter seems too much like a punishment, paint a picture or go for a bike ride.
The challenge is to find a balance that allows our humanity its due.
The rule of thumb is easy to say but hard to do: Seek balance in time and emotional equilibrium between online and offline engagement. Trial and error is a part of the process. By the time you get it just right, the kids will be going off to college, and they will have the skills they need to manage the online jungle on their own.
As the New Yorker cartoon famously observed about a dog sitting at a computer, “on the Internet no one knows you are a dog.” People who have issues with their self-esteem are both attracted and entrapped by the lure of being whatever they want to be online. Nothing wrong with fantasy as such. Many of us build castles in the sky. But only a few of us try to move into them; and those that do so are headed for trouble for so many reasons.
Children have to be 13 years or older to sign up for Facebook, and it is on that platform that we will concentrate here. The risks to children of all ages are real: online “cyber bulling,” vulnerability to predatory adults, sharing too much information, identity theft, and exposure to age-inappropriate content from advertisers, news, or stranger danger. The possibilities of getting paranoid about stranger danger are very real, but, as has been noted repeatedly, just because you are paranoid does not mean that they are not out to get ya.
As regards the age limit, I am grateful for it, and I see it as a useful reason to deny access to children of tender age, who lack readiness for the risks of the online world: “I did not make the rule, and it seems sensible to me.” Unless the child is actually working on a project with NASA, I see no reason to make an exception for children under 13. “But Susie’s mom lied to help her get an account!” As my mother used to say when I wanted to play in traffic like the other kids: “Yes, everybody is doing it; but you shall not!” The challenge is to figure out where is the boundary and how to navigate it.
A word of caution to policy makers: Do not make a rule prohibiting that which you cannot enforce. A heavy hand is counter-productive.
For example, thousands of adults did not even know they were interested in drinking alcohol until the 18th Amendment to the US Constitution prohibited it in 1919. Then drinking alcohol suddenly became strangely attractive. Likewise, Susie did not even want to get online until someone told her that she could not do so. The prohibition creates the desire.
To make matters even more challenging, the boundary lines keep changing. Such is the case with social networking. Computers, tablets, and smart phones are widely available, and unless you are planning on moving the family “off the grid,” youngsters need to be taught how to use social networking sensibly, safely, to have fun, and be productive with it.
To err is human, really to mess up requires an Internet connection.
Imperfect but empathic human beings try to navigate unempathic, imperfect social networks. This in itself is the business case for empathy-centered design of human and system relatedness. This is sometimes called “usability” testing. The computer system must be useable by error prone human beings. This points to another parental rule of thumb: if one’s experience of the computer is not useful or productive or if it is not fun, then a “time out” is in order. Say three words. Not “I love you,” but “Pull the plug.” Same idea.
Empathy lessons for parents of kids going online
What are the empathy lessons for parents around screen time, devices, and the relationships of kids with personal technology? Closely related to this question about how much time online is too much, is the issue of how best to manage the time children do in fact spend engaging with computer devices.
Children are great imitators. They want to be just like the adults, who seem constantly to have their noses buried in their electronic devices or a phone glued to their ear. Even when parents are at home, they are not fully present. Think about it. Grown up behavior speaks volumes to the children.
The good example parents set in laying aside electronic devices and relating in person to other persons speaks volume to the children. So does any behavior that demonstrates a parent’s commitment to drama or using social media to drive personal conflicts.
The authority with which a phone call, text, or email arrives from work, and the parent drops what she or he is doing to attend to it, says everything to the child. The rest is just a lecture that lands like “blah, blah, blah.”
On the spectrum of guidance extending from empathy all the way to tough love, here is the tough love for parents regarding the amount of time spent online, on screens: Look at your own example.
If you interrupt your conversation with your child to attend to a call, email, or text, you are an enabler. You were perhaps expecting the child to behave otherwise? You have demonstrated, clearly nothing is more important than attending to beeping, barking electronic appliances. The text or call is more important than your child. Your empathy is in break down. Ouch! Clean up your act.
A recurring theme of these lessons is that authenticity is the foundation of the work we are doing on empathy, and so before talking to the children about their use of electronics, come clean about your own electronic inauthenticities.
The empathy lesson? Set boundaries. Look for balance. Be responsible. Own it. Manage the amount of time children and young people spend on their screen by empathic parenting. Children of all ages are sensitive to any discrepancies between what grown ups say and what they do. Empathic parenting is about boundary setting. With older children, “first you do your homework, then you go to the mall (or play a computer game).” Children of all ages will inevitably test the boundaries, so have an explanation that privileges what you value about community, healthy personal relations, and friendship.
With electronic devices, rather than set an arbitrary number of hours that probably cannot be enforced, begin by creating an electronic device free zone. Start with dinner if your family is able to eat together or perhaps designate a time on the clock such as 8 to 9 pm to quiesce the electronics. This is good sleep hygiene too.
Rather than be negative, think positively. It is not just turn off the computers; but, especially for children of tender age, turn off the computer and let’s read a story book together. Turn off the computer and let’s play blocks. Turn off the computer and let’s play catch (weather permitting). Visit with friends in person. For older kids, dance lessons, gymnastics, science club, chess club (where you sit across from a real person), organized sports, hobbies, or arts and crafts. This will surface the parent’s ultimate inauthenticity. Just as in the days of old, when the parent used to sit the kid in front of the TV as a form of baby sitting, likewise with computer games.
Nothing is wrong as such with harried parents pushed down into survival occasionally using screens as baby sitters. Just be aware that something is missing from the virtual reality milieu—the first person relatedness of a human being with another human being. Within limits, nothing is wrong, but something is missing—empathy. I doubt that virtual reality is like the “good enough” parent. When virtual reality crowds out real reality—authentic human presence, then the time has come to call a “time out” on the use of devices.
For young people who are teenagers, the idea is similar. Don’t be negative; rather substitute something positive—and then turn off the device. Sports? Dance lessons? Cooking lessons? Tai Chi? Jogging? Volunteering at the Jaycees? An ice cream social? Window shopping in person? The opportunity is to teach social skills that require relating to another human being who is present at hand in person.
The mirage of popularity migrates online, too, especially as children enter middle and high school. The details differ, but the psychology of puberty does not. The influence of peer groups, which are emotionally (though not financially) more important to the teenager than family, is a standard part of the developmental process of separating from parents and leaving home to contribute to the community at large. The volatility of emotions due to hormones combines with experimentation, resulting in a high level of stress (for all): “I hate you! Drop me off at the mall?” This too shall pass.
Teenagers are experimenting with identity, emerging sexuality, and boundaries of all kinds. Why should they not experiment with online boundaries, too? The guidance is the same: “Check in! Don’t hurt yourself.”
At least prior to going away to college, the 13–17 year old group continues to require guidance and limit setting. If the teenager is involved in after school activities, is attentive in doing her or his homework, and has some friends who periodically show up in person, then the teenager is developing in a wholesome way. There is limited time for online networking and online misadventures.
The isolated individual, the socially awkward teen, for whom being online is a substitute for getting out of her or his comfort zone, is the concern. Perhaps the individual has experienced shaming or bullying. Or the individual is so sensitive that thoughtless statements that bounce off of most kids are experienced as hurtful. Here the amount of time spent online is the symptom of a problem, not the cause. I repeat: the symptom, not the cause.
When the child clings to his device and cannot be separated from it as if it were the beloved teddy bear, then, speaking personally, I start associating to the disturbing experiments with severely deprived macaque monkeys of Harry Harlow.[iii] Separated from their biological birth mothers, these monkeys clung desperately to the piece of cloth on the wire surrogate mother, even though it did not have a nipple. They would rather go hungry than forego contact with the cloth, surrogate mother. Heart breaking.
Restricting online access when that may be the main thing holding the teenager’s shaky sense of self together is likely to cause more conflicts, breakdowns in relatedness, withdrawal, and expanding isolation, not emotional equilibrium or empathy. Restricting online access does not provide the longed for balance. Further upsets and disagreements are predictable.
The challenge is that the teen is precisely at risk of re-enacting online an emotional upset similar to that with which he is struggling offline. What then provides the emotional equilibrium and deescalates the conflict?
If the parent has a relationship with the teenager, it is time for a heart-to-heart conversation—actually a series of them. Something is troubling the teen, and a grown up needs to find out what it is and take corrective action. Trouble at school with academics? With peers? If it is trouble at home—serious illness in the family, pending divorce, or financial setbacks—then these have to be surfaced, called out, and acknowledged. If the teenager is still unresponsive to parental overtures, then professional intervention may be required.
So much for the tough love. Now for the empathy. For children, especially of tender age, play is serious business. Group activities—whether play dates for younger children or organized clubs for older ones—activate and develop social skills, including empathy, whereas screens tend to isolate. That is so even if the screen is networked to include other players, who, however, do not necessarily show up as anything other than a function of the computer system.
The child’s job is to develop her emotional and cognitive abilities through the productive imagination activated in play. In so far as computer games and explorations can promote play and be integrated into play, all well and good. Yet the screen is intrinsically limiting, appealing to the reproductive, repetitive imagination. Still, many kinds of play do not require a screen.
For example, the graphics and images of the Magic School Bus are engaging, especially for children of tender age. The school bus becomes a space ship (or submarine or time machine and so on) voyaging out to explore the planets in the solar system, undersea world, or the inside of the human body.
However, every kid knows how to play at being a rocket ship or air plane without electronics: you stick out your arms, make a rocket motor noise, and run around the dining room table—to a neighboring solar system. The child’s entire body is fully engaged in motion. The child’s mind is fully engaged in fantasy. The child’s full self is active. The child’s mind is expanded. My only concern is that the child does not think that one needs an electronic device to fly. Make believe does the job very nicely, thank you. The productive imagination knows no limits of screen size.
Do not underestimate the power of a large cardboard box such as one might use to deliver a washing machine or refrigerator. Cut a couple of holes in it, and it becomes a space ship or the bridge of the RMS Titanic. Given some crayons or felt tip pens, it can be decorated with the markings of NASA or a personally invented team. Cut another hole in it, and it becomes the castle in which Sleeping Beauty is a prisoner or it becomes the Spirit of Saint Louis making the first solo transatlantic flight. If the computer game promotes imagination and innovation, then take the game and act it out by playing “make believe” with an actual cardboard box that Carmen the Explorer can use as a motor boat to sail up the River Nile. Bon voyage!
How to understand the child’s and the teen’s relationships with technology?
How should parents understand the relationship that children have with their devices in terms of empathy or lack thereof? Just as a teenager would not be allowed to drive a car without lessons and passing a test, access to the fun features of social networking comes with responsibilities. In both cases, one can hurt oneself and others. I am not advocating licensing online users—which would be an unconstitutional restriction of free speech (we can’t go there now!). However, new privileges imply new responsibilities. For teenagers and emerging adults, “Don’t hurt yourself (or others)!” remains essential guidance at all times.
The teenager needs to understand that there are some people “out there” in cyberspace who are not only not nice but dangerous in rather unpleasant ways. Do not click on communications that seem to arrive with authority from an unknown source or supposedly from a friend, but something just doesn’t seem right. What to do? Ask a grown up? Find someone who is computer savvy. The Help Desk should tell you: “Don’t click. Delete. If it’s important, they will pick up the phone or send a letter.”
As with any privilege, teenagers test limits. Recommend the Golden Rule: Treat others as you yourself want to be treated online and off. If it seems mean, do not do it. That means no devaluing language, no being mean to those who may be struggling with family or school issues, and speaking with integrity.
Kids immediately get it that “on the Internet no one knows if you are a dog.” Why is the creation of fantasy (i.e., fake) identities online any different from when kids used to brag, “I got more stuff from Santa Claus than you did!”? It is harder to get caught? Perhaps. Even if parents have their children’s passwords and access to their online resources, no one has time to monitor all the back-and-forth drama to which teenage life is prone. No one aspires to operate a mini-NSA (one of the spy agencies). Rather trust—but verify. Verify empathically. Spot check. Listen empathically for signs of upset or devaluing language. Watch for unexplained changes of mood and so on.
I repeat: trust—but verify empathically. Manage by exception—and if an exception shows up, then express concern and ask for her or his side of the story. Give a warning that the unacceptable behavior must stop—if the child is the perpetrator—whether cyber bullying or cheating or spending hours gossiping. If the questionable behavior does not stop, then see above—pull the plug. Confiscate the electronic appliance for a specific time period and until a commitment is forthcoming to change the behavior.
However, what if the electronic device is a smart phone and the child needs it to “check in” or coordinate pick up after school? If the family is affluent enough for the child to have a smart phone, then the family is affluent enough for the parent to swap out the smart phone for a flip phone or dumb device that enables a simple phone call. Take the SIM card out of the one and put it in the “dumb” phone. I wish there was an easier way, and, yes, it has come to that! Take away the teenager’s electricity, the ultimate form of “being grounded.”
Now after this significant digression into cyberspace and its challenges, we take the conversation back up a level, returning to the work of expanding empathy in the world of authentic human interactions, of which none are more important than those with our children. Many adults and teenagers will benefit from these recommendations, but they are initially for children of tender age.
Empathy lessons with children
(1) Lead by example: When parents demonstrate the ability to take the point of view of other people in solving problems, children learn by example. When parents demonstrate emotional drama and complaining, children learn by example. Be the role model that you want to see your children imitate. Be an example of the change you want to see.[iv]
(2) Speak in the first person: Use “I” as a way of establishing a firm boundary between self and other. “I don’t like it when you that word ‘x’. It hurts my feelings. Please stop it.”
(3) Validate the feelings of other people: “Sally is feeling angry because you took her ball. Please give Sally her ball back and then pick another one to play with.” In other cases, validation does not necessarily mean agreement; but it means recognizing that the other person does indeed feel the way she feels. Validate by finding the grain of truth in the other person’s perception.
(4) Use play to get access to how other’s feel: Talk with children of tender age about feelings and empathy as you play. For example, you might have your child’s stuffed dog say that he does not want to take turns with his friend, the stuffed tiger. Then ask your child: “How do you think tiger feels? What should we tell this silly dog?”
(5) Empathize with your child: As a parent you are a significant source of insight into what your child is experiencing. “Are you feeling sad that Sally cannot come over and play? That is a disappointment. She wanted to come; but she got sick and has to stay home. She can come next Friday. In the meantime, we can call your friend Jane and see what she is up to.”
(6) Suggest how children can be empathic: “Let’s make Sally a ‘Get well soon card’ and send it to her in the mail.”
(7) Validate your child’s upsetting emotions: Help the child understand what he or she is experiencing. Instead of immediately trying to substitute a positive emotion for anger, sadness, or fear, acknowledge that feelings can be upsetting. Identifying and validating upsetting feelings helps children to manage them: “You are really angry that I turned off the computer. I understand. You were playing your race car game. It’s okay to feel angry. When you are done being angry, you can join me fixing a sandwich for lunch.” Thus, children learn that feelings are important, but feelings do not have to run our lives. Feelings make us human and show us interesting things too.
(8) Be responsible for one’s actions and the consequences: Instead of rushing to have the child of tender age say “I’m sorry” when he has hurt another child, hit the pause button. Many children do not even know the meaning of the words “I’m sorry.” Rather invite the child to look at the consequences for the other child’s feelings and well-being. “Jane, why do you think Sally is crying? What happened? She skinned her knee when you pushed her. Let’s see if she is okay. Let’s get her some first aid. Here is some petroleum jelly and a bandage.” Sometimes the consequences of our actions escape from us. Help the child make the connection between the action (pushing) and the consequences (a skinned knee and crying).
(9) Be patient: Practice patience if a toddler or a child of tender age does not get it right the first time out. The parent may not even know whether or not the child of tender age literally understands what is being said. Be prepared to wait before judging and assessing based on ongoing, future behavior. Indeed throughout many of these examples, the cynical take away may be: “Hey, these parents seem to have time to relate to their children. Wouldn’t it be nice?” Empathy is never needed more than when it seems there is no time for it.
(10) Teach the child to identify feelings and emotions: Provide guidance in how to recognize emotions in others. We try to teach a child, who fusses and bangs on his high chair because he wants more milk, to say the words: “More milk, please!” The words are not a description of his feeling of hunger or impatience; rather the words substitute for the expression of hunger or impatience. Likewise, the word “pain” is not a description of the sensation of throbbing when the child has jammed his toe, it is an articulation in human speech that expresses upset and provides an alternative to screaming.
We teach our child well to use sentences like “I hurt my toe!” as a substitute for crying in pain. Shouts of distress are the natural expression of pain, but are notoriously unhelpful in determining the particulars. We substitute expressions such as “my toe hurts” for natural expressions as tears or cries of pain.
Given the nuances of human experiences and emotions, and the relative lack of explicit training in expressing them, it is not surprising that many people lack skill in identifying and communicating feelings and emotions.
Simultaneously, we work with children on recognizing such experiences in others. It is often easier to see that Sally is in distress, crying due to a scraped knee, than when that happens to the child himself (who is then preoccupied with his own “owie”). We work from both the outside in and from the inside out, and eventually meet in the middle, being able to communicate our experiences and emotions to others and ourselves. Meanwhile, when relationships have become weaponized, as in bullying then the issue has to be how to implement a disarmament plan. The issue is how to de-weaponize relationships. In the following and third post in this series, I directly address students, parents, and teachers/administrators with recommendations.
[i] September 18, 2021: “The Facebook Files: A Wall Street Journal Investigation,” Jeff Horwitz, Keach Hagey, Newley Purnell, Sam Schechner, Emily Glazer: https://www.wsj.com/articles/the-facebook-files-11631713039?mod=hp_lead_pos7 See also: Mike Isaac and Scott Shane. (2017). Facebook’s Russia-linked ads came in many disguises, The New York Times, Oct 2, 2017: https://www.nytimes.com/2017/10/02/technology/facebook-russia-ads-.html [checked on Oct 15, 2017].
[ii] I express my thanks to Firas Nakshabandi, MD, for conversations, ideas, and input on social networking and raising children. Very thoughtful; very empathic.
[iii] Harry F. Harlow. (1958). The nature of love, American Psychologist, 13, 673– 685.
[iv] These recommendations, liberally adapted with acknowledgement and thanks to Claire Lerner and Rebecca Parlakian. (2016). How to help your child develop empathy, Zero to Three: Early Connections Last a Lifetime: https://www.zerotothree.org/resources/5-how-to-help-your-child-develop-empathy [checked on June 26, 2017].
(c) Lou Agosta, PhD and the Chicago Empathy Project
Empathy as presence – online and in shared physical space
Review: Gillian Isaacs Russell, (2015), Screen Relations: The Limits of Computer-Mediated Psychoanalysis and Psychotherapy. London: Karnac Books: 206 pp.
Granted in-person physical meetings are impossible when the health risks become prohibitive, that is no longer the case (Q3 2021), at least temporarily. Therefore, the debate resumes and continues about the trade-offs, advantages and disadvantages, of online telecommunication (“Zoom”) mediated therapy sessions versus physical in-person work.[1]
Gillian Isaacs Russell’s book in a powerful and important counterforce to trending technological optimism that online therapy is the wave of the present and of the future. This optimism compels those of us who are digital immigrants to align with digital natives in privileging screen relations over physical presence in the same space in engaging in psychoanalysis and psychotherapy. By definition, “digital immigrants” were educated prior to the explosion of the Internet (and world wide web on) or about the year 1999 and “digital natives” came up with “online everything” such as pouches for their smart phones in their parents’ baby strollers.
The cyber rush to judgment is slowed if not stopped in this hard-hitting critique of online screen relations. Isaacs Russell wisely asserts skepticism that meeting online (even in a pandemic) and meeting physically in person are “the same.” One may eventually go ahead with online therapy in many situations (especially in a pandemic), but if you are hearing “they are both the same” that is reason for a good healthy skepticism that the purveyor of the online approach is being straight with you. One also needs to be skeptical as online therapy starts out being “better than nothing” only quickly to slide in the direction of “better than anything.” As usual, the devil – and the transference – is in the details, and Isaacs Russell provides insight in abundance to the complex issues.
Speaking personally, in my own work on empathy, published in 2015, the same year as Isaacs Russell’s book, my Preface concludes with the ontological definition of empathy as “being in the presence of another human being without anything else added” – anything else such as judgment, evaluation, memory, desire, hostility, and the many factors that make us unavailable to be in relationship (Agosta 2015; see also 2010). Though Isaacs Russell uses the word “empathy” in a specific psychological sense, I would argue that her work on “presence” is consistent with and contributes to an enlarged sense of empathic relatedness that builds community.
Isaacs Russell has interview psychoanalysts, clients (clients), over several years and reports in a semi-ethnographical style on the trade-offs between online mediated relations and those which occur in the same physical space, such as a therapist’s consulting room. Her arguments and narratives are nuanced, charitable, and multi-dimensional. The reader learns much about the process of dynamic therapy regardless of the framework.
What she does not say, but might usefully have called out, is that the imperative is to keep the treatment conversation going, whether online or physically present in person. When someone I am meeting with in-person asks for an online session, after controlling for factors such as illness of a child at home or authentic emergencies, then my countertransference may usefully consider the client’s resistance to something (= x) is showing up. In contrast, when an online client asks to come into the office, one may usefully acknowledge that the individual is deepening his commitment to the work. In neither case is this the truth with a capital “T,” but a further tool and distinction for interpretation and possibility in the treatment process.
Isaacs Russell makes the point (and I hasten to add) that no necessary correlation exists between the (digital) generation divide and enthusiasm (or lack thereof) for online screen relations of baby boomers versus millennial or gen-Xers. Some digital immigrants are enthusiastic about online therapy, whether for authentic professional reasons, including economic ones, or to prove how “with it” they are, and growing numbers of digital natives are becoming increasingly skeptical about the authenticity of online relations, craving physical presence without necessarily being able to articulate what is missing.
Isaacs Russell provides an informative and wide-ranging briefing on developments in baby watching (child development research). Child development is a “hands on” process of physically relating to another emerging human being. Her point (among many) is that we humans are so fundamentally embodied that in some deep sense we are out of our element in reducing the three dimensional, heat generating, smell-broadcasting mammalian body to a cold two-dimensional video image. Though she does not do so, Isaacs Russell might usefully have quoted Wittgenstein: The human body is the best picture of the soul (1950: 178e (PPF iv: 25)). As the celebrity neuroscientist A. Damasio notes: [We need] “the mind fully embodied not merely embrained.” What then becomes of the relatedness when the body becomes a “head shot” from the shoulders up on a screen?
The answer is to be found in the dynamics of presence. Key term: presence. Physical presence becomes tele-presence and the debate is about what is lost and (perhaps) what is gained in going online. The overall assessment of Isaacs Russell is that, not withstanding convenience and the abolition of distance, more is lost therapeutically than gained.
Although Isaacs Russell does not cite Wittgenstein, Heidegger, Husserl, and Merleau-Ponty loom large in her account of the elements of presence. Much of what Isaacs Russell says can be redescribed as a phenomenology of online presence, including the things that are missing such as smell, the ability to physically touch, aspects of depth perception, and the privileging of “on off” moments over against gradual analogical transitions. The above-cited philosophers were, of course, writing when the emerging, innovative, disruptive technology was the telephone, and Heidegger himself went “off the grid” physically (and morally!) with his semi-peasant hut in the Black Forest near Freiburg, Germany. But even though they never heard of a mirror neuron, the distinctions these thinkers lay down about relatedness are fundamental for work in communications and human understanding.
Isaacs Russell gives the reader a generous tutorial in breakthrough developments in neuroscience, including the discovery or mirror neurons in Macaque monkeys and a neurologically-based mirroring systems in humans, which account for key aspects of empathy, intersubjectivity, and human social-psychological relatedness.
Since this is not a softball review, I must inquire, following detailed descriptions of embodied cognition, the primacy of movement in empathic relatedness, faces as emotional hot spots (which nevertheless incorporate full-bodied clues as to the exact emotion), kinesthetic and proprioceptive feedback: do we need a psychoanalysis or rather do we need an aerobics class (okay, at least a class in Tai Chi, moving meditation)? The point is that both participants may indeed “forget” about the computer-mediated relation, but the unconscious does not. The (unconscious) transference is also to the technology and needs to be engaged, interpreted as such. Isaacs Russell provides the distinctions to do so, which is what makes her contribution so valuable, even if one disagrees with her ultimate skepticism that online is the wave of the future.
Amid many useful distinction and nuances, as noted above, the key-differentiating variable for Isaacs Russell is presence. She connects this closely to D. W. Winnicott’s seminal work on enabling the client to recover the ability to “go on being” in integrity and individuality, even in the presence of another person. The model for this therapeutic process is the young child’s breakthrough in individuality as the child is able to be alone (e.g., playing) in the presence of the mother (or care-taker).
This process of becoming an individual being gets operationalized and tested when the client tries to destroy the therapist and the therapist [demonstrates that s/he] survives. Here “destroy” is a technical term, though it does indeed invoke hatred and the possibility of aggression. The paradigm case is that the client expresses hostility – even hatred – towards the therapist and the therapist does not retaliate. The therapist “takes it,” metabolizes the aggression and responds appropriately setting an empathic boundary in the relationship. This advances the treatment, expanding the integrity, autonomy, and individuality [mostly] of the client.
According to Isaacs Russell, this is the key moment – the differentiator: “In ‘screen relations’, the client can never really test the analyst’s capacity to survive” (p. 37).
Why not? Isaacs Russell quotes an astute client (in so many words) that without being in the same shared space the potential for the client or therapist “to kiss or kick” the other is missing. The potential for physical desire or aggression has been short circuited. Since the treatment must engage with these variables, the treatment is stymied and deprived of essential enriching possibilities of transformation.
Isaacs Russell is adamant that the ability of the therapist to survive, in Winnicott’s sense, cannot be test in the online context. If it could be significantly tested, then much of what she writes about the inadequacies of online presence would be invalidated or at least significantly reduced in scope. As noted, Isaacs Russell makes much of the potential to “kiss or kick” the other person in the same physical space; and it is true that such acting out rarely occurs but what is needed is the potential for its occurring.
However, what has been overlooked is such acting out bodily is not the only way of testing the separation and survival of the therapist. Many examples exist in which the client tests the limits by means of a speech act – seductive or aggressive language. Speech is physical and would not occur with the sound waves impacting the biology of the ear. This is not merely a technical point. Tone of voice, rhythm, and timing are physically available.
The distinction “speech act” is one that is critical path in any discussion of the talking cure, even if the latter is understood in an enlarged sense to be the encounter of two embodied (not merely “embrained”) talkers and listeners. Speech act theory includes pragmatics that allow for the illocutionary and perlocutionary force of speech. Speech does not merely describe things – it performs things, building connections and relations. People get other people to do things – change the physical environment – by speaking to them: close the door! Pick up the kids at soccer! Persons invested with certain kinds of conventional authority, powerfully change relationships and other aspects of the human world. For example: “I now pronounce you man and wife” spoken by the officiating authority at the wedding. This is a new reality – in so many ways. The empathic response of the therapist, spoken to the struggling client, is another such example.
Language is powerful, and we humans both wound and heal through our words. Heidegger, who is usefully quoted by Isaacs Russell as inspiring the work of Merleau-Ponty regarding physical spatial dynamics also noted, “Language is the house of being.” That is, presence – physical, mental, poetical, historical – emerge in the conversation that we have individually and in community in language.
Recall that Winnicott’s point is that when the client acts out – in this case verbally – the therapist demonstrates his survival skill by not retaliating. Thus, s/he remains in integrity as a “good enough” partner in empathic relatedness and becomes independent. This likewise rebounds to the expanding integrity and independence of the client.
If the therapist does retaliate – say by moralizing or withdrawing or blaming or becoming aggressive or seductive – then the possibility of treatment in the relationship is short-circuited. Absent significant repair, the relationship ends, even if the conversation continues in an impasse for awhile longer.
Speaking personally, and omitting confidential details, I recall an instance online where, being clumsy with a relatively new online client, who was vulnerable in a way that I did not appreciate, I triggered a challenge to my survival. I triggered a combination of panic, retraumatizing flashback, and panic, in the client that resulted in an extended and seemingly automatic combination of verbal abuse. It threatened me professionally and the safety of the client such that I seriously thought of sending emergency services to the client’s address. The screen is always the screen, in this case, but the screen was no protection against the impact of the hate. It is a further question whether the same thing might have happened if my clumsiness had occurred in person. Perhaps the client would have kept quiet and never returned. We will never know.
So while the client might not effectively have been able to throw a pencil at me (to use Isaacs Russell’s example), the individual would have been able to inflict self-harm in a way that would do more damage to me than a kick in the shins (another Isaacs Russell example). Never underestimate the ability of clients to innovate in acting out around the constraints of an apparently firm therapeutic framework.
The good news is that, without making any commitments I couldn’t keep, by a combination of soothing statements, placating statements, self-depreciating humor, apologetic words, and deescalating inquires and suggestions, I kept my wits about me, and was able to restore the integrity of the therapeutic process. S/he agreed to continue the conversation. I survived and so did the relationship. It actually was a breakthrough, and, without everything being wonderful, the client demonstrated capabilities that had not previously had going forward.
Thus, the counter-example: Survival was tested online, not by physically throwing a pencil, but in reciprocal speech acts and the enactment of presence in speech, a physical media not to be underestimated. One learns that the environment is safe when safety breaks down. To Isaacs Russell’s point, the potential for non-survival also includes non-survival as an actual enactment and outcome – and neither online nor physical presence has a privilege in that regard.
In a real world emergency – a credible threat of self-harm – there is a difference between sending emergency services to the client location and summoning them to one’s own office. But perhaps not that much. The point about survival, safety, and containment (different but overlapping issues) and their respective breakdowns is the same. Many distinctions exist between an online and physical encounter, but the risk of survival or non-survival occurs in each context.
One may argue back that the risk of a meltdown is less extreme in the warm and cozy confines of one’s own office, but maybe you never met a borderline client like this particular one or a client as suspicious or deeply disturbed. If the client takes out a box knife on camera and starts to carve up her or his inner thigh (or threatens to do so), one may fervently wish that s/he kicked one in the shins instead.
Thus, in answer to the potential for “kicking or kissing,” the answer is direct: Oh, yes the client can – can indeed test the capacity to survive and do so online. The example “kiss or kick” is not a bad example, but many counter-examples exist that provide useful evidence to the contrary as cited above.
Positively expressed, plenty of evidence is available that the analyst’s survival can indeed be tested in an online session and s/he may survive or not. Ultimately even “kiss and kick” can be enacted as verbal abuse on line, perpetrating boundary violations with hostility or seduction that can be grave and survival threatening, either in imagination or reality, including the survival of the therapist as a professional and the therapy itself.
To give the devil his (or her) due, it is true that there are some cases that are decidedly unsuited for an online engagement. Marion Milner engaged in a celebrated analysis of a deeply disturbed and regressed client, in which the client was silent for long periods of time.[2] The client finally was able to recover significant aspects of her humanity in producing hundreds of drawings and sketches that expressed a therapeutic process of pre-verbal recovery. It is true that, though these were visual artifacts, and presumably might have been communicated remotely, the client herself was already so “remote” from reality that another layer of virtuality was not going to work (nor was it possible mid-20th century).
Heinz Kohut has a celebrated example that he presented in an lecture made a few days before his death. Kohut was working with a deeply regressed and suicidal client (client) in years gone by. In a desperate moment, Kohut offered to let the client, lying on the couch behind which he was sitting in his customary straight-backed wooden chair, hold two of the fingers of his hand. The point of this potentially life saving (and boundary testing) gesture was Kohut’s association to the client’s desperate grasp with her hand being like that of a toothless infant sucking on a nipple. An empty nipple or a life giving one? Powerful stuff, which of course, would never be possible online. Far be it for me to be the voice of reality, nevertheless, these two cases of Milner and Kohut are outliers, albeit deeply moving one, that are completely consistent with the sensitive and dynamically informed application of online analysis and dynamic therapy.[3]
Though the uses of extended moments of online silence should not be underestimated or dismissed, Milner’s and Kohut’s cases were ones that privileged physical presence. It in no way refutes the power or potential of online engagement. What are missing are criteria for telling the difference. No easy answers here but the rule of thumb is something like: do whatever is going to further the treatment in the proper professional sense of the words. What is going to sustain and advance the conversation for possibility in the face of the client’s stuckness? Do that. Winnicott has been mentioned frequently, and rightly so. He spoke of the “good enough” mother. Here we have the “good enough” therapeutic framework including the online one.
Another part of the narrative that was particularly engaging was Isaacs Russell’s discussion of ongoing online psychoanalytic training with the colleagues in China. There are few psychoanalysts in China, so in addition to significant culture and language challenges, such remote work would not be possible without online analytic therapy sessions and supervision. The nearly unanimous consensus is this is valuable work worth doing. The equally unanimous consensus, about which one may usefully be skeptical, is that this work is “functionally equivalent” or in other ways “just the same as” work done physically in person.
The author provides examples, whether from the Chinese colleagues or other contexts is not clear, where neutral observers are asked to evaluate transcripts of sessions where the online versus physical feature and descriptive details have been masked. The result? They can’t tell them apart. What more do we need to say?
Apparently much more. With dynamic psychotherapy and related forms of talk therapy if you can tell the difference between an online and an in person meeting (other than comments about traffic or Internet connections), then you are probably doing it wrong or there is some breakdown that interferes with the process (in either case). Abstinence is easier online – no hugs. But if we are talking boundary violations, maybe some people – exhibitionists? – are tempted to take off their clothes on camera. (This has not happened to me – yet.) Anonymity – just as one’s office has clues as to one’s personal life, so too does the background on camera. Neutrality – being on camera suddenly causes one to adopt a point of view on social media or politics or nutrition or economics or education? Perhaps but I am not seeing it.
However, what Isaacs Russell does not discuss is the “other” transcript – the unwritten one, which is only available as a thought-experiment. There is another transcript different than the verbatim account of what was said or even what a web cam could record. It is a transcript that is just as important as the recoding of the conversation, and why verbatim recordings of the conversation are less useful than one might wish. Both participants may “forget” that the session is being recorded, but the unconscious does not. There is the transcript of what the people are thinking and experiencing, but remains unexpressed or expressed indirectly. Such an aspect of the counter-transference or thought transcript is harder to access and includes the therapist’s counter-transference.
One thing is fundamental: When the context of the encounter between people is an empathic one, then both an in-person encounter in the same physical space and an online encounter via a video session are ways of implementing, applying, and bringing forth empathy.
The online environment and the imaginary thought transcript present new forms of client resistance and therapist counter-transference, and it is these that now are the main target of the discussion of this essay.
Moving therapy to online opens up a new world of symptomatic acts, parapraxes, “Freudian” slips, and acting out.
I had one online client who stands up in the middle of a session to check on what this individual had cooking in the oven, carrying her camera-enabled device with her. Was I amazed? Indeed.
I acknowledged to the client that clients sometimes have mixed feelings about their therapists, and nothing wrong about that as such. Yet I was wondering did she believe I was perhaps half-baked? Key term: half-baked. Further discussion occurred of whether this individual was expressing her unconscious hostility towards me – while, of course, also preparing a baked dish.
The breakdown in empathy may be a thoughtless remark by the therapist, a mix up in the schedule, or a failure of the computer network. The empathy – and transmuting internalization working through it – LIVEs in restoring the wholeness and integrity of the relatedness. Empathy lives as spontaneous relatedness, a form of transference and vice versa. This is not limited to psychoanalysis versus psychodynamically informed psychotherapy. This is not limited to online versus physical therapy.
Other than candidates for psychoanalytic training, few people are calling up practitioners are saying: “I want the most arduous, rigorous, time-consuming, expensive treatment known – I want a psychoanalysis!” I tend to agree with Isaacs Russell that the possibilities for doing full-blown remote psychoanalysis are – how shall I put it delicately? – remote, but not necessarily due to any features of the online environment.
After all the dynamics and debates are complete, Isaacs Russell ends her book with a masterpiece of studied ambiguity. She gives an account of a conversation in an online session with a client in London, UK. Isaacs Russell has relocated to Boulder, CO, USA. Having worked together in physical presence, the client misses her and Isaacs Russell misses the client – yet the therapeutic conversation continues. One cannot help but agree with the sentiment – there is something missing – and yet the conversation continues. Thus, we roundly critique cyber therapy – and go off to our online sessions.
[1] Acknowledgement: This reviewer first learned of Gillian Isaacs Russell’s penetrating and incisive engagement with all matters relating to online psychoanalysis and psychotherapy from my friend and colleague Arnon Rolnick in Q2 2021 as the 2020 covid pandemic was waning, at least temporarily. Thus, I am catching up on my reading.
[2] Marion Milner, (1969), The Hands of the Living God: An Account of a Psycho-analysis. London: Routledge, 2010.
[3] Charles Strozier, (2001), Heinz Kohut: The Making of a Psychoanalyst, “Gentle into that Good Night,” New York: Farrar, Straus, and Giroux: 376–377.
References
Lou Agosta, (2010), Empathy in the Context of Philosophy. London: Palgrave Macmillan.
Lou Agosta, (2015), A Rumor of Empathy: Resistance, Narrative, Recovery in Psychoanalysis and Psychotherapy. London: Routledge.
Lou Agosta, Ph.D., Listening With Empathy 