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Bassen, C. R. (2007). Telephone Analysis

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Cecile R. Bassen
55/3
TELEPHONE ANALYSIS
W
arren Poland introduced the panel by posing a seemingly
simple question: What is the place of the telephone, and what
is its impact on analyses conducted by phone? Is the use of a telephone
a variation of frame, or is its concomitant physical distance and absence
of visual contact so crucial as to alter the essential analytic situation?
Poland stressed the need to search for evidence instead of responding
from theoretical preference, and noted that none of us is immune to
a common occupational hazard: the bias that how one works as an
analyst is good, while how others work is open to question. We have a
tendency to feel moral condemnation toward those who threaten our
accepted principles, and this occurs whenever anyone suggests a change
in technique. To facilitate the work of the panel, Poland offered a
working def inition of analysis as a two-party therapeutic engagement
based centrally on inquiry, in which the mind of the analyst is placed in
the disciplined service of facilitating the expression, exposure, and
exploration of the workings of the patient’s mind. In that context, the
exploration of underlying meanings and the power and effects of unconscious forces is what defines the work as psychoanalytic. He asked
each of the panelists to give a brief description of his or her clinical
experience with telephone analysis in order to promote a discussion;
he suggested that those who feel that no true analytic work can be
carried on by phone try to hear the views of those who feel otherwise,
and that those who dismiss all arguments for discipline as old-fashioned
orthodox rigidity try to hear the panelists’ questions about the price of
this change in technique.
Charles Hanly summarized his experience with K. He continued
analysis by phone at her request when she left Toronto after a year of
analysis on the couch, preceded by psychotherapy. Hanly was reluctant
Panel held at the Spring Meeting of the American Psychoanalytic Association,
Seattle, June 12, 2005.
Panelists: Warren S. Poland (chair), Charles Hanly, Jane V. Kite, Sharon Zalusky.
Discussant: Stanley J. Coen.
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to attempt a phone analysis, but agreed because there were no analysts
in the area K. relocated to. He described K. as successful but narcissistically vulnerable; she experienced panic attacks, which had diminished
in the first year of analysis. Hanly was concerned about a loss of the
holding function of the transference and of affect-stimulating proximity,
and worried that use of the phone might provide a protective distance
resulting in unanalyzable resistance, but his fears proved unfounded.
The analysis continued at four times a week for three years until termination. Before her move, K.’s transference was primarily positive and
idealizing; however, she felt affectively alienated from her father, and
in the negative paternal transference experienced anxiety that her analyst found her boringly uninteresting. To Hanly’s surprise, the telephone facilitated the useful development of an erotic transference; in
the absence of repeated visual contact, K. began to experience him as
younger. Although before her move she feared being left alone by a lack
of interest from Hanly, she now drew gratifying, soothing reassurance
from the sound of his voice on the phone. The analysis of K.’s wish to
be sensually attractive to Hanly led to a deep realization of her rivalry
with her mother, which earlier she had been unable to recognize.
Hanly’s acceptance of her request for phone analysis also led to a
further working through of the paternal transference, resulting in deidealization, trust in her appropriate aggression on behalf of her needs,
and a growth in self-confidence. Hanly concluded that the essential
processes of free association, transference, understanding, and instinctual maturation need not be compromised in telephone analysis. He feels
that the basic interpretive, responsive, holding, and witnessing functions
can be sustained by the analyst without a need for modifications.
The discussion that followed centered on patients’ ability to tolerate the analyst’s physical absence. Glen Gabbard noted that he found
himself talking much more on the phone with a patient who could not
tolerate silence, and wondered if Hanly might have talked more with this
patient who experienced anxiety about being isolated and abandoned.
Hanly replied that he had expected that K. might have difficulty tolerating both the couch and the phone, but he had not found this to be the
case; however, he noted that he is a talkative analyst. Poland commented that Salman Akhtar has written about the issue of nearness and
farness, and the analyst’s trying to keep the distance right. Patients in
Poland’s office sometimes ask “Are you asleep?” but on the phone they ask
“Are you there?” This suggests that the task of titrating the distance differs.
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TELEPHONE ANALYSIS
The value of meeting in person periodically was also raised.
Michael Robbins commented that he has had extensive experience
with phone work as a result of having relocated twice. He was astonished by the positive outcome with one patient, who he didn’t anticipate
could tolerate the distance; Robbins found weeklong visits, two to
three times a year, important in sustaining their relationship. Hanly
noted that he met with K. on occasions when she visited Toronto. He
had expected these sessions would be critically important, but did not
find them so. However, they did help her become aware of the extent to
which she was picturing him as younger than his age on the phone and
erotizing the transference. Henry Smith noted that he too has experienced an intensification of erotic transference on the phone with a
patient who in his office had been inhibited in talking about her erotic
life and her experience of her body. Smith suggested that this may be a
common, potentially useful, occurrence.
Sharon Zalusky opened her presentation by saying that she believes
that there are significant differences between telephone analysis and
analysis that takes place in the office; she feels it is our responsibility
to examine what we gain and what we lose in doing analysis by phone.
Each participant in telephone analysis has to create and sustain a
mental representation of the other in fantasy, because the physical
presence of the other is not available. In doing so, a new analytic dyad
is created and a new analytic process emerges, since the analyst in fantasy and the patient in fantasy are never the same as the two who have
met in the office. Rather than being diluted, transference may in fact be
intensified. Telephone analysis pushes Freud’s rationale for the use of
the couch to its extreme limit: without the visual interference of the
analyst, the transference ripens. However, this may be hidden from consciousness. Zalusky feels it is important to schedule occasional office
visits, since transference distortions may not stand out until analyst and
patient are reunited in person. She offered a vignette from a productive
telephone analysis in which an important aspect of the transference
remained hidden from both patient and analyst until they laid eyes
on each other during an office visit. Her patient stated, “You look so
different. You aren’t my analyst who’s with me on the telephone. In my
mind you are so much older than you really are. My analyst is old and
frumpy. You are neither.” They were able to go on to analyze the
meaning of this transformation. Zalusky suggested that telephone
analysis focuses, concretizes, and condenses such basic analytic issues
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as separation, loss, availability, and the needs of both patient and analyst, as well as the analytic frame and deviations from it. The use of the
telephone for some may truly be a transitional space; hearing the voice
of the other, repeatedly over time, while there and not there, helps create a mental representation of the caring other. Like all technology, it
also blurs the boundaries between fantasies and action (Zalusky 2000).
A member of the audience volunteered that she’s been in an
extremely productive phone analysis for several years. In her own
experience as a patient, the inherent connection between analyst and
analysand is a critical sustaining factor. Although she never felt a
connection with her first analyst, she established a good connection
with her second analyst and found it easy to transition to phone work
when she moved. She wondered if it was essential to establish that connection in the office first. Zalusky replied that there is no one way to
begin or to conduct phone analysis; she has heard of telephone analyses that were productive even though analyst and patient never met
in person. Poland noted that while some things are gained, we also
need to attend to what is lost, including the analyst’s ability to attend
to and make use of shifts in body posture, in ways that McLaughlin
and Jacobs have described.
In her presentation, Cecile Bassen emphasized the therapeutic
value of analyzing patients’ fantasies about the possibility of continuing by phone whenever an analysis is disrupted by the patient’s or
the analyst’s move, independent of the ultimate outcome. When Bassen
told her patients that she was moving, several expressed interest in
continuing by phone. She found that the wishes, feelings, fantasies, and
fears behind each patient’s desire to continue, including any wish to
avoid or deny the fact that she was ending the work as they had known
it, were specific to his or her dynamics. Inquiring about why one patient
did not raise the option of continuing by phone uncovered her fantasy
that Bassen had decided to stop being an analyst, a fantasy related to
the patient’s deep, painful feelings of abandonment by her mother after
her parents’ divorce. This led to new material about the patient’s rejection of her mother’s attempt to maintain phone contact, and a significantly revised understanding of her long estrangement from her mother.
Bassen noted that for children of divorce, continuing a relationship by
phone carries meanings specific to their experience with noncustodial
parents. Citing Poland’s working definition of analysis, Bassen suggested that exploring the underlying meanings of the analyst’s or
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TELEPHONE ANALYSIS
patient’s move and the patient’s wishes, fears, feelings, and fantasies
about continuing by phone is consistent with analytic inquiry, rather
than simply assuming that an analysis should either continue or end.
Jane Kite presented her experience with a female patient who after
three years of analysis, and as the result of a job change, began alternating between two weeks of analysis in the office and two weeks by
phone. This experience led Kite to conclude that important shifts of
feeling are catalyzed and sustained by physical presence in a way that
may be impossible when only the auditory mode is available. Kite’s
patient dislikes calling and routinely calls late. The patient has expressed concern that either of them could be psychically absent in the
phone sessions, and dislikes Kite referring to the two of them as a “we,”
especially on the phone, where she feels so separate. It as if the patient
were saying, “We are only potentially a we when I’m here, and even that
is a stretch.” Kite feels she is working too hard to engage her patient in
phone sessions, as if they are constantly in danger of losing the connection. The patient feels peaceful being with her analyst in the office;
it’s something she wants and values, which is aesthetically different
from talking on the phone. In one session held in the office, her associations to the collapse of a building led her to articulate her feeling that
the connection they’ve built together in person is wrecked on the
phone, and the “point of being here” is lost. An erotic dream led to further associations that having her analyst to herself in the office felt like
winning, while talking by phone felt like losing and being left out. Kite
commented that her patient’s difficulty sustaining the sensory dimension of her perceptions in the analyst’s absence has made them aware of
something that was not previously accessible, the degree to which the
office setting functions as a maternal presence.
The discussion that followed concerned what one can learn from
the changes that occur when analysis switches from the office to the
phone. Carol Levin recounted that exploring whether or not to continue
by phone when one of her patients moved led to the uncovering of a
fantasy about the analyst’s eternal availability that previously had not
been accessible. Sue Von Baeyer described two different experiences
with phone work: a patient who is intermittently psychotic has called
her while sitting with her in her office, using the analyst’s voice in her
ear to calm herself; the other patient provocatively describes being in
unsafe situations when he calls for phone sessions. Henry Smith noted
that when an intense transference and countertransference developed in a
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treatment that he began by phone, he found that neither he nor the patient
wanted to meet in person; there can be an intense holding on to a
mental representation or fantasy developed in absence, with a
reluctance to allow this to be challenged by reality. Jane Kite commented that the patient she described remembered her erotic dream at
the end of the second hour of the week, after reestablishing contact with
the analyst and reclaiming her object representation. She suggested that
the erotic transference may be overdetermined in phone work, if it
emerges in part in an effort to hold on to the analyst.
A member of the audience raised some practical questions, particularly the issue of who should call whom. Another, who had been in
phone analysis, volunteered that she preferred to call her analyst; this
allowed her to prepare for the session, just as she prepared when driving to her analyst’s office. Warren Poland confirmed that most phone
analyses seem to be arranged that way.
Stanley Coen, as discussant, repeated Poland’s concern about
our tendency to make assumptions based on our biases and preferences, and noted that analytic couples will vary in their preferences.
Coen emphasized the importance of keeping our eye on the ball—that
is, keeping our focus on psychoanalytic understanding of psychical
reality rather than on the physical reality of patient-analyst contact—
and of subjecting listening and looking to our usual psychoanalytic
inquiry instead of assuming we know what they mean. Coen felt that
the presenters were drawing on early childhood models of the construction of object representations too concretely, and making too
sharp a differentiation between listening and looking. He questioned
the panelists’ assumptions that looking allows the patient to see transference distortions that can be challenged and corrected, and emphasized the value of wondering why patients’ perceptions and feelings
change instead of assuming we know the answer. Coen felt that Kite’s
conclusion that her patient was unable to maintain an object representation of her was premature. Noting that psychological incapacities in
our patients often turn out to express conflicts in their feelings and needs,
he speculated that Kite’s patient may dislike phone sessions because she
craves her analyst’s physical presence and hates not being physically
close to her. He feels that we are too concrete if we assume that patients’
reports of aloneness, emptiness, or absence represent actual loss of an
essential object representation, rather than seeing them as defensive,
rage-filled attacks on the missing object. What is missing, empty,
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TELEPHONE ANALYSIS
negative, lost, dead, destroyed, or nonexistent should not be taken at face
value but needs to be examined for its vital meanings. Coen feels that we
do better to try to help our patients, whatever the formal arrangements,
rather than attribute too much to the telephone or to the consulting room.
We risk losing our psychoanalytic perspective in overconcern with its
formal arrangements.
Hanly said he appreciated the emphasis that Coen placed on meaning. He noted that though philosophically we tend to emphasize the
primacy of vision, and have a deeply rooted bias that “seeing is believing,” language is the medium of exchange in analysis and auditory
functions are absolutely crucial because of the connection of language
to meaning. Hanly felt the evidence presented at the panel made it clear
that analysis can be carried out by telephone and the view that it cannot
be is untenable.
Zalusky responded that she was fundamentally in agreement with
Coen. She feels that a great deal had changed in her patient as a result
of analysis, which enabled the patient to see Zalusky differently when
they met in person. However, even though telephone analysis can be
extremely effective, it remains a therapeutic compromise, and we need
to be sensitive to the fact that there are certain people for whom it is
too depriving—it leaves them feeling dropped. For some patients, the
absolute presence of the other may have the most mutative effect, especially at the beginning of treatment.
Kite felt that some of the distinctions Coen drew were too pat.
She feels that the difference her patient experiences between sessions
in the office and sessions on the phone is not about looking, as much
as what it is like to be in the presence of the other. Kite feels that
her patient’s experience illustrates André Green’s comment that “the
psyche is activated by the object’s proximity” (1975).
Bassen emphasized the degree to which individual differences
in dynamics affect the meaning of conducting analysis by phone. She
wondered whether Hanly’s agreeing to K.’s request to continue by
phone despite his reluctance led to her feeling special, facilitating the
development of the erotic transference. In contrast, it might be particularly difficult for someone like Kite’s patient, who was struggling with
whether she could experience the analytic dyad as a “we,” to tolerate
phone analysis. These individual nuances are likely to affect the patient’s
ability to hold the analyst as an internalized object in the absence of
physical proximity.
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Poland commented on the value of differentiating psychic from
physical space. Michael Robbins noted that he has had one psychotic
patient tape their sessions, and no one has been able to discern the difference when he plays tapes of face-to-face and phone sessions with
this patient. He does insist on establishing a face-to-face relationship
before beginning phone work, and on having some intermittent contact;
this allows him to attend to the importance of the contrasting experience, whether it has to do with fantasy or the meanings of physical
presence. However, Poland noted that with some patients it is simply
not possible to meet in person at any point in the treatment. Coen volunteered his experience with patients in psychotherapy who use the
phone to establish a safe distance when they feel things are getting too
intense and they are afraid of being overstimulated; later they are able
to come into the office and talk about it.
Robbins uses a headset when he is on the phone and is aware of
being freer to move around; he suggested that it is worth wondering
about the implications of what we allow ourselves to do in phone sessions and of what patients do. Hanly commented on the issue of unwitting boundary violations; he called a schizophrenic patient when
she missed a session in an effort to provide a holding environment, and
she felt he was involved in a sexual situation with her because she
was naked. Smith suggested that comparing work on the phone to work
in the of f ice provides an opportunity to learn about the nature of
psychic life and motoric discharge, including what aspects of talking
on the phone may stimulate the erotic transference (such as having
the analyst’s voice in one’s ear, the association to phone sex, and the
lack of physical constraint).
The analyst’s countertransference was also discussed. Poland
volunteered that the discussion led him to realize that his countertransference has affected the way he begins telephone analysis. He
explicitly states that he doesn’t know if it will work or not and that
each party has an obligation to speak up if it is not working. He had
never stopped to question his singling out phone analysis in this way,
even though he has the same feeling about beginning every analysis,
or to think about the pressures and burdens his comments introduce.
Ann De Lancey commented that a marked change occurred in a
child analysis when it became a phone analysis due to the family’s
move: the pressure for object removal the child was experiencing in the
office disappeared. However, when she was asked to inform the child
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of a parent’s suicide, De Lancey wanted so much to have the child
in her presence and experienced the physical distance as excruciating.
Kite noted that knowing she would see a child patient the next day
made a similar experience bearable for her. She feels it is important
to recognize that phone work can be chaotic since you never know what
will impinge from the side of the patient; this can be difficult to contain and metabolize.
Sherwood Waldron brought the discussion back to the emphasis
Coen placed on keeping our eye on what we’re trying to accomplish.
He sees the analyst as a well-informed guide accompanying his patient
on a journey, who is not necessarily well informed about the terrain.
Child analysts expect the journey to involve actions as well as words,
and are accustomed to letting the child define the communicative path.
This happens with adults in a less obvious way. We never know what
direction the journey will take, or what will prove to be important. If
we are willing to let our technique be formed by our patients and
the circumstances with a reasonable degree of comfort, it helps us keep
our eye on the ball. Poland concurred with the value of following
the patient’s lead, commenting that Waldron had provided a beautiful
description of analysis. Coen noted that struggling in a rigid way about
what works and what doesn’t, or having a set idea of how it should
be, gets in the patient’s way.
As the panel concluded, Poland noted that we need to acknowledge that many analysts are conducting telephone analyses and begin
to examine all these issues. Both Hanly and Coen emphasized the
reality that at times, when either analyst or patient is in a remote area,
there is no other way to provide treatment.
REFERENCES
G REEN , A. (1975). The analyst, symbolization and absence in the analytic
setting. International Journal of Psychoanalysis 56:1–22.
Z ALUSKY, S. (2000). Infertility in the age of technology. Journal of the
American Psychoanalytic Association 48:1541–1562.
4033 East Madison Street, Suite 202
Seattle, WA 98112
E-mail: cbassen@hotmail.com
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