If ever there was a time for online (tele/cyber) talk therapy, this is it.

In case you were trekking through Tibet or living in a cave with Buddhist monks, allow me to clarify why. Key term: social distancing.

It is not that anyone who is sick or symptomatic would knowingly go to an in-person

Cover art: Theory and Practice of Online Therapy, eds., Weinberg and Rolnick

therapy session anyway, nor does one have to avoid mass transit or public taxis or garage attendants (who may park one’s auto while coughing on the steering wheel). Reasonable accommodation works well. Yet just because you have a germ phobia or are getting clinically paranoid does not mean you cannot get physically ill!

Therefore, keep calm – and carry on – I mean: wash your hands!

Okay, this is not funny. The lesson? Psychotherapy 101 teaches us that the most fearsome thing is – the unknown.

You know how in the vintage black and white monster movies, once you actually see the guy dressed up as Swamp Thing, it is a lot less scary? The creature may still be disgusting, but it is no longer nearly as scary? The scary part is when the heroine is innocently combing her hair and the swamp thing (which is “off camera” and the audience cannot yet see) is silently sneaking up behind her.

You know that scenario? Well, that’s what we’ve got here with the World Health’s Declaration of a pandemic. I will not further comment on the details as numerous resources are available from WHO and the Center for Disease Controls, frequently updated as we learn more and more about what to do or not do.

Just as many businesses, schools, colleges, universities are working remotely – that is, online – for example, delivering a webcast online, clients and therapist may leverage the convenience and social distancing of online therapy for their therapy sessions. One can also apply the lessons of social distancing in an in-person office setting, but it has to be a reasonably large office (which I do have) about the distance of two sneezes across. However, that is not what I am talking about here. What am I talking about? Download a video telecommunication application (function) such as Zoom (this is just an example, not a product endorsement), which reportedly uses encryption. Then review the instructions or call the Help Desk (which I am not operating for purpose of this post).

I cut to the chase. Here are two lessons learned since I originally published this post about online (cyber) therapy in September 13, 2019.

First, an online session presents new opportunities for the equivalent of slips of the tongue. There was one individual with whom the occurrence of the word “mother” was inevitably followed by the Internet connection freezing up, requiring a restart. You can’t make this stuff up. After I called it out, he stopped messing with the volume controls, which seemed to have occasioned pressing the wrong button. Therefore, in an empathic space of acceptance and toleration, the therapist may reasonably provide understanding, accommodation, and some extra time to reinforce and support relatedness.

Next, I can see many psychiatrists, psychologists, and clinical social workers with contracts with insurance companies getting stressed because insurers generally resist paying [will not pay] for tele-consultation (or will do so only (say) in Alaska where there is no other provider within 200 miles).

That is definitely an issue; and it will not be solved here. It may require an act of Congress to curb expanding monopoly rents on the part of insurers during a national crisis, and I would be in favor of such action. It is true (as far as I know) that one cannot take someone’s blood pressure over Skype, though I would not rule out some innovator coming up with an attachment that connects to the computer’s USB. In any case, I am not holding my breath, and I am continuing to expand my online empathy consulting practice, since – how shall I put it delicately? –  my relationship with insurers is actually more than a distance of two sneezes across and, in many cases, breaks down in that an empathy deficiency is not [properly speaking] a medical diagnosis.

Update: March 17, 2020: This just in from The Washington Post: “Medicare expands telemedicine to allow seniors to get virtual care at home” [https://www.washingtonpost.com/world/2020/03/17/coronavirus-latest-news/#link-FAF2A2J73BDH3FH6GUHMGM5OSE] This is progress – and it is about time!

Meanwhile –

Meanwhile –

The following was published on September 13, 2019 and is repeated here as highly relevant to our current wellness challenges.

The genie is out of the bottle. The day that the first therapist invited his one-on-one client (who had an urgent need for a conversation but an inability to get to the office) to put down the phone and dial into Skype, the genie escaped from the bottle.

The reader will recall that in the 1001 Arabian Nights the Genie was very powerful but a trickster and nearly impossible to control. Making wishes is tricky, and if one is not careful, the sausages end up stuck to one’s nose and one must waste the last wish to get them off. In this case, the Genie is Internet technology such as Skype and Google Groups and the emerging conveniences, affordances, complexities, entanglements, and even resistances that it offers.

In the Arabian Nights, the hero, Aladdin, had to trick the Genie to getting back in the bottle by appealing to his narcissism. “You are not all powerful,” Aladdin said. “A large creature like you could not possibly fit in that small bottle!” The Genie’s wounded narcissism caused him to prove that he can indeed fit back in the bottle. Aladdin puts the stopper back on – trapped! However, in the case of the Internet and online communication tools, do not look to be able to turn back the clock.

But there is good news. The human face is an emotional hot spot. It is rich in micro-expressions many of which are available and visible even though the “real estate” on the screen in less rich in detail than an in-person experience. Indeed it is not even clear that the face as presented online is “less rich.” It is the only thing being displayed, and the viewer is led to concentrate on it in detail. But here the trade-off of bodily presence versus the imaginary comes into the foreground.

The criticism fails that the online conversation between persons lacks the reality of the in-person encounter. But this criticism fails, in a surprising way. The criticism fails not because the online media is so real. Rather the criticism fails because the in-person psychotherapy encounter is shot through-and-through with the imaginary, with symbolism, the imaginary and irreality. The “irreal” includes the symbolic, the imagined, the fictional, the part of reality which is distinct from the real but includes the past and the future and the imaginary, which are not really present yet influence reality.

In psychotherapy, the in-person encounter is precisely about the symbolic and the imagined – the transference. The basic definition of “transference” is that the person relives emotionally the relationship to objects (persons) from the past, persons who are not physically present in the room (or in the virtual space online).

What we are calling the “virtuality” of the technology media adds an additional dimension of irreality to the symbolic and imagined transference relationship. Yes, the media is the message (as Marshall McLuhan famously wrote), but with the arrival of online therapy the media is first and foremost the transference. The message now occurs with a strike-through, message.The online technology itself becomes a source and target of transference.

The one thing that immediately occurred to me: Psychotherapy invokes a virtual reality all of its own – even without cyber space. This is especially the case with dynamic psychotherapy that activates forms of transference in which one relates to the therapist “as if” in conversation with a past or future person or reality, the latter not physical present. Indeed, with the exception of being careful not to step in front of a bus while crossing the street on the way to therapy, we are usually over-confident that we know the reality of how our relationships work or what people mean by their communications. This is less the case with certain forms of narrowly focused behavioral therapies, which are nevertheless still more ambiguous than is commonly recognized. Never was it truer that meaning – and emotions such as fear – are generated in the mind of the beholder.

While virtual reality (VR) goggles as such are not a part of any online therapy group process, VR goggles are currently being used in individual psychotherapy with clients who are dealing with phobias and related individual issues.

[See www.psious.com– an engaging start up which is promoting the VR goggles for psychotherapists. The author (Lou Agosta) reports: I have no financial relationship with this company, and I wrote a blog post in 2016: “A Rumor of Empathy at Psious”: https://tinyurl.com/jyuxedq]

For example, it is much easier for someone with a fear of flying to put on a set of VR goggles in the therapist’s office and take a virtual trip to the airport, board an airplane (in VR), and be taxing down the run away (in VR), than it is to do this in the real world. The next step in a group process is to create an avatar that resembles one’s individual physical self, warts and all, and to join the other avatars in an online virtual reality group session. New possibilities are opened up by this form of therapy for dealing with all kinds of emotional and mental issues that are beyond the scope of this article.

Here the point is just to look at how virtual reality (“virtuality”) already lives in the in-person psychotherapy session even as it might have been conducted in 1905.  There is a strong sense in which the conversation between a client and a psychodynamic therapist already engages a virtual reality, even when the only “technology” being used is a conversation is English or other natural language.

For example, when Sigmund Freud’s celebrated client, Little Hans, developed a phobia of horses, Freud’s interpretation to Hans’ father was that this symbolized Hans’ fear of the father’s dangerous masculinity in the face of Hans’ unacknowledged competitive hostility towards his much loved father. The open expression of hostility was unacceptable for so many reasons – Hans was dependent on his father to take care of him; Hans loved his father (though he “hated” him, too, in a way as a competitive for his mother’s affection); and Hans was afraid of being punished by his father for being naughty. So Hans’ hostility was displaced onto a symbolic object, the horse. Hans’ symptoms (themselves a kind of indirect, “virtual reality” expression of suffering) actually gave Hans power, since the whole family was then literally running around trying to help him and consulting “The Professor” (Freud) about what was going on. In short, the virtual reality – now remove the quotes – made present in the case is that the horse is not only the horse but is a virtual stand-in for the father and aspects of the latter’s powerful masculinity.

So add one virtual reality of an imagined symbolic relatedness onto another virtual reality of a simulated visual reality (VR) scenario, the latter contained in a headset and a smart phone. Long before VR technology, therapists of all kinds, including behaviorists, used VR by activating the client’s imagination by asking him or her to imagine the getting on the feared airplane. One may try to escape virtual reality by not going online, but the virtuality follows as long as human beings continue to be symbolizing, imagining creatures.

This blog post is an excerpt from: Lou Agosta’s article “Empathy in Cyberspace: The Genie is Out of the Bottle” in Theory and Practice of Online Therapy: Internet-delivered Interventions for Individuals, Groups, Families, and Organizations edited by Haim Weinberg and Arnon Rolnick. London and New York: Routledge: To order the complete book, click here: Theory and Practice of Online Therapy [https://tinyurl.com/yyyp84zc]

(c) Lou Agosta, PhD and the Chicago Empathy Project

The Theory and Practice of Online Therapy: Internet-delivered Interventions for Individuals, Groups, Families, and Organizations, eds., Haim Weinberg and Arnon Rolnick, published by Routledge:

Table of Contents

Acknowledgments

Introduction to the book Haim Weinberg and Arnon Rolnick

Section 1 General considerations for online therapy edited by Haim Weinberg and Arnon Rolnick

Chapter 1 Introduction to the general consideration section: principles of internet-based treatment Arnon Rolnick

Chapter 2 Interview with Lewis Aron and Galit Atlas

Chapter 3 Empathy in Cyberspace: the genie is out of the bottle Lou Agosta

Chapter 4 Sensorimotor psychotherapy from a distance: engaging the body, creating presence, and building relationship in videoconferencing Pat Ogden and Bonnie Goldstein 

Chapter 5 The clinic offers no advantage over the screen, for relationship is everything: video psychotherapy and its dynamic Gily Agar

Chapter 6 Cybersupervision in psychotherapy Michael Pennington, Rikki Patton and Heather Katafiasz

Chapter 7 Practical considerations for online individual therapy Haim Weinberg and Arnon Rolnick

Secion 2 Online couple and family therapy edited by Shoshana Hellman and Arnon Rolnick

Chapter 8 Introduction to the online couple and family therapy section Shoshana Hellman and Arnon Rolnick

Chapter 9 Interview with Julie and John Gottman

Chapter 10 Internet-delivered therapy in couple and family work Katherine M. Hertlein and Ryan M. Earl 

Chapter 11 Digital dialectics: navigating technology’s paradoxes in online treatment Leora Trub and Danielle Magaldi 

Chapter 12 Practical considerations for online couple and family therapy Arnon Rolnick and Shoshana Hellman 

Section 3 Online group therapy edited by Haim Weinberg

Chapter 13 Introduction to the online group therapy section Haim Weinberg

Chapter 14 Interview with Molyn Leszcz

Chapter 15 Online group therapy: in search of a new theory? Haim Weinberg 

Chapter 16 Transformations through the technological mirror Raúl Vaimberg and Lara Vaimberg 

Chapter 17 Practical considerations for online group therapy Haim Weinberg 

Section 4 Online organizational consultancy edited by Rakefet Keret-Karavani and Arnon Rolnick

Chapter 18 Introduction to the online organizational consultancy section Rakefet Keret-Karavani and Arnon Rolnick

Chapter 19 Interview with Ichak Kalderon Adizes

Chapter 20 All together, now: videoconferencing in organizational work Ivan Jensen and Donna Dennis

Chapter 21 A reflexive account: group consultation via video conference Nuala Dent 

Chapter 22 Practical considerations for online organizational consultancy Rakefet Keret-Karavani and Arnon Rolnick 

Epilogue Arnon Rolnick and Haim Weinberg