Covid-19 Reflections II

My Experience of Working Online

 

About twelve years ago I first started working online in response to a request from a patient when I was thinking of moving from London to the Bath area. I was at first unsure of the desirability of working online because of the loss of not being in the same room as the patient and also because of my anxiety about confidentiality. Because of the importance of confidentiality I consulted a senior person who worked in security. When I expressed my concern about working online, he smiled and explained that they now have equipment that can be focused on any window from about a mile away and they can hear every word that is spoken in that room. In order to avoid this you would need a room that is in the basement of the building with a metal door. However, he added that the people who have this equipment are only interested in State and Commercial secrets and have absolutely no interest in our work. In other words my belief, at that time, was that working in my consulting room was more secure than working online: this turn out to be absolute nonsense. I also found that my patients and supervisees were very concerned to work online in a place that provided them with privacy. In other words, it was they who didn’t want to be overheard and therefore, without any encouragement from me, would work in as secure a place as possible.

Most of what I have read on the subject has been written by people with very little experience which results in the negatives being emphasised. It is of course the case that all our skills and theories are based on clinical experience and where there is an absence of experience then there is bound to be anxiety. As I gained experience I found that as both, my patients/supervisees and myself, began to relax and then I found that I was quickly getting back to maintaining my ‘analytic attitude’. Of course, I still prefer to see patients in my consulting room because you gain a great deal of information from vision and all the senses. However, when working online, I found I became much more attuned to every sound that the patient makes. Obviously analysis online is a great deal better than no analysis. In addition I have found that with experience, I have done a good deal of good work which is not only my assessment but is what my patients have experienced. One of the test of this is that, although I now only work part-time, I currently have four patients who I have been working with online for the past twelve years. One of the attractions of working online for patients is that it saves them a great deal of time and trouble in travelling. I do not have the vision on when working online which is similar to patients using the couch.

Much to my surprise I have found supervision to be better online. Having given this a lot of thought I think the reason for this is that when meeting a supervisee in person a certain amount of energy goes into persona (social) activities whereas when working online the energy is focused on studying the material. It can involve me in a little more work in that a few of my supervisees send me their process recordings before our online meeting but this gives me a better understanding of the dynamics of the therapeutic relationship. In relation to energy that is used by the persona, one criticism I have heard is that working online can result in 'slippage'. This statement was made because the analyst may remove their shoes or wear casual clothing. My believe is that what is being described relates to the persona whereas what matters for me is - 2 - not the 'shop window' but the inner true self and that is my main focus. There is no 'slippage' of my analytic attitude. When I first started working online I found that there was a period when both my patients/supervisees and myself had to get used to the technology. In other words there is the reality of a learning period. But before this there is the paranoid anxiety associated with the unknown. Interestingly, this seems to be mainly the case with some adults. Children, on the other hand, see computer and other electronic equipment as an opportunity to play. I think that the reason for this is that when some adults face the unknown it activates their early traumas. As Winnicott says, “. . . where playing is not possible then the work done by the therapist is directed towards bringing the patient from a state of not being able to play into a state of being able to play.” There is a part of me that hopes that this very short paper may enable those with anxiety to slowly move into playing with what online work can offer. However, we must first look into the anxiety: Klein makes the point, “. . it is not only that the infant’s feeling about the external world are coloured by his projection, but the mother’s actual relation to her child is indirectly, and in subtle ways, influenced by the infant’s response to her.” Seeing the online computer as at times representing the mother, then we are faced with an often difficult or unresponsive mother. Thus, paranoid fantasies are activated. As is the case with all paranoia, there is a tendency to exaggerate the negatives. This accounts for many adults being very anxious, irritated and dismissive towards working online. In Jungian terms where something is unknown then we project the contents of our shadow.

Thus, the persecutory/attacking/witch like mother is created. Mostly this process is unconscious. The conscious justifications that I have heard are: ‘We have not been trained in that way.’ and ‘We should stay with what our key psychoanalytic figures have said.’ Again, the unknown is assumed to be against what we do know or that what we know will be diminished or lost. Whereas my experience is that when we become used to the difficulties and limits of working online our basic training comes back into play; i.e. we are able to re-instate our analytic attitude of working in the here-and-now and focus on our relationship with the patient, namely, transference/countertransference. I have also been just as able to get into the patient’s feelings of fear/shame/persecution/hate and slowly unpack their origins in order to integrate these very important inner states. I could go into all of this in more detail, but the aim of this very short paper is to provoke ideas and help people to reconsider the subject of working online. I will repeat that I prefer to be in the same room as my patients but I have found that I have been able to do some good sound work when working online.

At this moment in time we are facing the major problems brought about by Coronavirus. Thus, working online or by telephone become very important options. Nobody knows how long this virus will be with us but the general view of the medical profession is that it will be with us for at least several months. From an ethical point of view, working online or by telephone becomes essential. Each patient we see is a new learning opportunity and I hope this paper will encourage colleagues to be open to seeing that working online is a new learning opportunity.

 

Hugh Gee