Monday, April 9, 2012

Telephone Treatment - The Reluctant Psychoanalyst Earns Continuing Education Credit



A couple of weeks ago I went to a Mandatory Continuing Education workshop.  Now, I didn’t have to go to this particular workshop – it is mandatory that I receive 20 hours of continuing education every two years, and three of those hours have to be in the area of ethics in order to maintain my license in psychology.  This workshop offered the needed ethical credit, and it was on an area that has been of great interest to me: Provision of psychological treatment via phone and the internet.

I have wandered into providing service via phone and email as many of my peers have done, a little bit at a time, reading as I go along, but also finding that the literature on treating at a distance is evolving, just as my practice is.  That said, I have always provided psychological services at a distance.  My very first training in the field was when I was in High School and I was a volunteer at a community mental health agency and I was trained on a suicide hotline.  I don’t think I fielded a crisis call during that stint, but I certainly fielded many during my next paraprofessional tour of duty in a halfway house for runaway teenagers when I was evaluating, after college and before graduate school, whether this really was the profession for me.

As a psychologist in training, then as a psychologist in practice, I fielded many calls – from clients asking about entering treatment to calls from established clients in crisis.  I have always felt comfortable using the phone.  It creates a particular kind of intimacy – a closeness and a safety – the safety of not being in another’s presence, that seemed to be actually quite psychoanalytic in nature.  If the couch is intended, in part, to relieve both analyst and analysand of being concerned with the other’s facial expression, if it is further intended to help the analysand construct the analyst as he or she will, doesn’t the phone do that to even greater levels?

So, when an analysand proposed meeting by phone during a period of travel, it seemed to make sense to me to try it and to see how it went.  And the answer, in so far as such things can be answered, seemed to be a mixed bag.  In some ways, there was that increased sense of intimacy – there was a sense of closeness.  On the other hand, I did not always know where we were meeting and sometimes that didn’t seem to be well thought out by the analysand and we needed to work on setting up appropriate places to meet.  More importantly, there was an interaction between what was talked about and whether we were talking in person or on the phone.  And it seemed like there were times when the analysand chose to set up the meeting by phone – for instance when there was particularly difficult material to discuss – as if being in the same room to talk about it would make it more difficult to address.  We were able to talk about this part of the process and to discover that it sometimes seemed to be the case that our difficult meetings were not consciously planned by phone but seemed instead to “work themselves out” in relation to unconscious motives.

I was fascinated by the interaction of the phone and motivations and talked with some of my peers who had been or were doing some of their own analyses by phone because they were commuting for training.  They resonated with the experience of my analysand and I and I briefly considered doing some research to investigate how the work of various analyst/analysand pairs was affected by including the phone as a means of doing the work.  I did not complete this project, but did some reading about the burgeoning field of telephone analysis and telephone psychotherapy more generally, so it was with some interest that I attended this workshop.

The workshop was led by the executive director of our state board of psychology and a member of the state psychological association who specializes in the use of technology in the practice of psychology (I consider both of them friends of mine).  After reviewing the evolution of phone, email, and other electronic communication use in psychological practice, the presenters noted that laws have not kept up with the spread of communication devices as a therapeutic modality.  They reviewed new laws that our state has put in place to protect the consumer of psychological practice – in particular, anyone treating someone who is currently in our state (whether they reside here or not) can only be treated by someone who is licensed in this state.   The intention of the law is to protect residents of the state from being harmed by someone practicing somewhere else and the citizen of our state having no recourse in case of malpractice.  The effect of this on the group was a little different, however.

The group, all practicing psychologists, began to fear that they would soon be breaking the law if they were to talk with their patients who were travelling in other states – or if the patient moved to another state and they continued to meet by phone.  As the person sitting next to me noted, the room began to be dominated by a powerful emotion: fear.  We all became psychologists for many reasons – but, I think especially when we were younger and more idealistic, foremost among those was the wish to help others.  From this perspective, a license to practice psychology was a means to do good.  It was like a driver’s license to a sixteen year old, an emblem of freedom – but in the case of the psychologist’s license, it is the freedom to provide useful and needed treatment.  Now, of course, it is and was also a means to a livelihood.  We anticipated that we would be able to charge for our services or be hired by an agency to provide them and this would become our livelihood.

In the group at the workshop (and I count myself in that group) it was the latter motivation that was dominant – and the resulting emotion – fear that our livelihood would be taken away – came to dominate our experience and our conversation.  We were consumed by the fear that we would do something wrong – illegal – and lost sight of the telephone and the internet as a means to more broadly do good works.  We were afraid that we would break the law – and also disdainful of the “counselors” that were called up on people’s smartphones who stood ready to provide counseling at rates that would be charged to a credit card by the minute.  While I share some skepticism about how useful that therapy “by the minute” might be, I must acknowledge that this may be a way of delivering service that is more in step with our current culture than I am comfortable admitting.  While it takes McTherapy to a whole new level, could it be that this is an entry point to the mental health field, a field that can be notoriously difficult for “consumers” to navigate?  Could reasonable referrals be made from such a means of being available?  While I am skeptical, I also wonder about the possibilities.  And more importantly, I am concerned that, once we have created a safe way of doing things, that we become closed to new and innovative means of addressing mental health needs.

When Freud shifted from applying mild electric currents to his patients’ numb arms and legs to asking them to tell him what came to their minds about their symptoms, this was a revolutionary shift in our approach to treating conversion disorders.  We now have very powerful treatments – and thus also the means of inflicting harm.  We need to protect our patients, but we also have an obligation to figure out ways of delivering the services that we offer to those who need them in ways that will work best for them.  It will be interesting to see how we move into this brave new world – and how we will balance our fears for our citizens and our fears for our livelihoods with our concerns for our citizens’ best interests and with using our license to work for those interests.    

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