Now "hear" this... The issue is not about getting too comfortable. The issue is so impressive upon our consciousness that we must ease into it and take a bit of a circuitous route.
Cyber technology and social media have conspired with some practical constraints to stimulate numerous changes in the practice of psychotherapy. Many people expect, or are prepared for, different dynamics from professional helpers than the usual 50 minute hour in an office that is rather emotionally plastic, even if the seating is wool and leather. There are movements to involve active computer interaction and diagnosis, as well as remote treatment, such as using Skype, etc. Insurance companies and clinical ethicists are striving to provide guidelines that are economically self serving and avoid undue liability. And of course, this is all in the name of providing the best care to patients and clients. Oh, Sigmund...
I have always delighted in the fact that he was born Sigismund Schlomo Freud. Just the sound of that name is stirring and evocative, and even joyful... As my own hearing has deteriorated a bit over the past several years, sounds are increasingly treasured. Over the years I wondered, as we often do, which sense I would rather be without, my sight or my hearing, and I usually concluded I would prefer to lose my hearing; I could not contemplate the question if the matter was considered a condition from birth. I then remember my first CPE supervisor, a man who had lost his sight as an adult and was a marvel to watch as he ministered throughout the large hospital where he was in charge of pastoral care.
Sigismund Schlomo...The sight of the words means little, but the sound of them is marvelous. And is it not also the case when people want to be "heard"? No one yells at their partner that the problem is that the dumbbunny didn't "see" him or her...no, you are a jerk because you didn't "hear" me!
Neurologists and neurophysiologists have remarkable opinions about the operations of the brain. Is the occipital cortex more complex than the auditory cortex? The occipital cortex seems to be better understood, but the auditory cortex may be far more complex in many ways. I would suggest in simple terms that the ears "see" far more than the eyes "hear". I believe that to be true.
In the therapeutic interaction, some have tried to include other senses such as touch, which has been heralded by many women as important. Documented abuse has addressed both men and women as perpetrators, and in any case, physical touch has been essentially proscribed from the professional psychotherapeutic interaction. Touch is out... Taste is out... Smell is ambiguous... So, we are left with sight and hearing.
In 1998 I began providing psychotherapy to persons who were not physically in my office. I had very specific conditions for this activity, which have eventually been incorporated into the standards of practice that are present today for pastoral counselors, marriage and family therapists, and a variety of clinical fields where such encounters are considered.
What became especially interesting was the experience of phone therapy vs. the emerging experience of therapy facilitated by developing technologies for video-conferencing and the evolution of widely available tools such as Skype. I began to observe an apparent contradiction. The supposed transparency and intimacy and engagement provided by the union of simultaneous audible and visual communication was not effective. It was illusory at best. The cases that used this advancing technology were less effective and intimate and engaging than the cases that relied on phone contact alone. The cases that employed only phone contact were more intensive, more transformative, and the patients sought to continue more in their exploration of their issues.
Could it be that, despite my need to raise the volume a bit, the cases that relied entirely on our non-visual interaction were more effective and productive and intimate and therapeutically significant? What about the importance of trying to "read" the non-verbal indices that are part of the visual portion of the vaunted audio-visual encounters?
When I presented this material in my collegial supervision and consultation, it became apparent that I had been putting more emphasis on MY ability to perceive what was presented through the screen and speakers in front of me, instead of experiencing the patient's revelation of personal and transferential information. I seems I had lost my therapeutic perspective; something about the media had seduced me or misdirected my attention.
There are several cartoons in my office that depict caricatures of clinical practice, including one where Schlomo is sitting behind a fainting couch. The caption is irrelevant but the image is a priceless reminder of the power of evoking the free expression and transference of the patient. No visual contact was required or desired. The transactions were oral and audible and unfettered by the body language of the patient or the visage of the therapist. Yes, "unfettered"...
I currently have patients in several parts of the United States and in Germany and Italy. In every case I utilize only the audible expression of content and interaction. In these clinical engagements I am as close to the "couch" as is possible in today's world. In my current office visits with local patients, I am beginning to encourage less and less face to face interaction. More content is being elicited in this shift, which I find amazing despite my journey as a clinician for over 35 years. I am ready, for many reasons, to make the "case for the couch".
I could go on for many paragraphs with more evidence, but all I would be doing is promoting truths there were evident over a century ago. Yes, it is not the patient who resists, it is the therapist, and therapist resistance is furthered by the ego of the clinician who needs to believe he or she is a real person in the process that heals the patient. We are functionaries, albeit ones that must be as well prepared and crafted as is possible. In the Christian tradition, we are at best the fit vessels of spiritual forces greater and more vital than we can ever imagine. We are most effective when we are an extension of the ego of the patient in crisis as he or she becomes the patient in process and the patient in victory. Schlomo the Jew did it in the context of his own belief or non-belief, and we can certainly strive to do as well.
____________________
William Scar
Diplomate, CPSP
Diplomate, AAPC
Approved Supervisor, AAMFT
Program Director, Good Samaritan Counseling Center/SCIC