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-20^th 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.

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^[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.