My approach to deepening and revitalizing development for patients has been to understand the parallel process. We evolve in relation to our patients, intersubjectively, with the psychological field of the patient intersecting with, and influencing, our own. As therapists, we need our visual cues and responses, but what is it like to work without those? To treat effectively remotely we must acknowledge that these patients often want to control their proximity to us, letting us into their world on their terms. We also must acknowledge that even though they are not visible to us, we must “see” them, and tolerate the absence of what is familiar to us. I have learned the importance of “seeing” and being seen in working with Beth, who was in treatment with me for 7 years by remotely. I should say that I never met Beth face to face.

Our relationship began when Beth, a 53 year old college counselor, responded to a blog posting of mine—a WSJ career blog. My posting had to do with age discrimination and how it is a reality when looking for a job. Beth reached out to me in my role as both a career coach and mental health counselor. She told me that she needed help deciding whether she should begin a masters degree program in counseling. This would be a career shift that would enable her to one day leave her current employer. She didn’t trust her own decision process and wanted a reality check. We agreed to meet via telephone (audio) since she lived too far from my office in Manhattan. Beth had had previous therapy, but left the therapist who had been bossy and critical of her decisions.

During our first session, I told her that because I couldn’t see her, I might often need to ask about feelings that might otherwise be obvious if we were meeting in person.

We began weekly phone sessions. Her history, as she told me, was that she procrastinated, wasted time and couldn’t get anywhere. Because I am also a coach, I often help my clients keep on track. My initial approach with Beth was to focus with her on her career decision process. In actuality, I realize she had already made the decision to move forward with a masters degree, and the impending change was frightening. I understood that she might need me as a soothing, idealizable presence as she ventured out beyond the familiar.

Because Beth was already a counselor, she talked about her cases. These sessions were often more like supervision sessions, in which Beth could speak freely about how to handle difficult counseling situations. But I felt a distance between us in these sessions. Letting me “see” her own clients, especially the difficult and challenging ones, was new for us. With her letting me see, but keeping a distance, I became aware of Beth’s need to manage our proximity.

A further deepening of our sessions emerged after 3 months when Beth complained that she couldn’t speak in a group because she wasn’t from a big family. Soon, her family and friends became a very real presence in our sessions. She spoke of friends who were sucking the air out of her, and her decision to not renew those friendships. She was determined to make changes, as she was increasingly aware of feeling suffocated in relationships.

During our first winter, Beth often felt like she was on “thin ice.” I could hear her elevated anxiety as she revealed this. I did my best to hold her, with small expressions of ‘knowingness.’ Ice became an important image for us. As a child, she had fallen once on ice, and no one had stopped to help her. She had to crawl to safety on her own. Another metaphor that emerged during these anxious memories was “chocolate;” it became a shared metaphor for getting cozy, for self-soothing. I could so identify, and chocolate also became a way of my finding myself in her (Togashi, 2008).

I was now realizing that Beth’s meeting with me over the phone met needs she had that were important to understand. She was taking her masters degree online as well. Outside of work, most of her contact was via computer or phone. She was divorced and lived alone. Her support system was limited to a few supportive colleagues at work, and her mother.

We now had been meeting for nine months of weekly sessions by phone, and Beth mentioned that she was a “large” woman. She wanted to lose about 25 lbs. In the next session, she mentioned that she had a professional organizer come to her apartment. She couldn’t throw things out, and needed help sorting through 20 years of stuff that had accumulated, perhaps unconsciously hoping that she could “have” enough. Two decades lost, as she said.

Beth had been meeting with me for a year by phone. This next session was, in fact, our one-year anniversary of working together. We had developed by this time a language of presence, often including embodied emotion…a felt sense.

Beth started the session in a sullen tone, “I give until there’s nothing left, and I get nothing back.” I feel her sense of depletion, and say, “It’s like you give until you’re empty; it’s hard to give and give and give without getting a response.” Yeah, I’m empty,” she says. “Beth, I hear the sadness in your voice. Can you tell me what you’re feeling now in your body…do you have a physical sense of that feeling?” “I’m curled up, holding myself,” she says. After a long pause (silent pauses on the phone are not at all easy), I say, “Everything is going to be all right, Beth, I can hold you.”

With that exchange, we were quiet for a while, hearing only each other’s breathing. Beth went on to tell me that day was the anniversary of her father’s death. She’d never before talked about her father. It had been a year to the day since she had first called me. Beth’s father became a ongoing presence in our sessions as I learned that her father had been the primary sustaining, loving relationship in her childhood. His presence in our sessions would be central to Beth’s recognizing her healthy strivings. The acknowledgement of the importance of her call to me on that very day a year ago represented a kind of developmental shift…Beth cried in a deep sobbing way that I had not heard before.

With the emergence of her father in our sessions, our work deepened again, as she also let me into her relationship with her mother. Since her father’s death, Beth had become the object of her mother’s narcissistic mortification, being denied love, being devalued and humiliated as an adult, just as Beth had been since childhood. Only now, one year into our work, did I realize that Beth was merged with her mother and unable to make even day-to-day decisions without her mother’s explicit approval.

Beth talked about her problems with intimacy, and with her family, at great length. Although, she was unable to get what she needed in any human relationship, she very gradually let me understand her relationship to food. Food gave Beth the only place where she could “get enough.” But the feeling was fleeting. Sweets—chewy, crunchy sweets—a pleasure for her, but filled her with shame and guilt.
We began talking for the first time more explicitly about her relationship to food. A BIG HOT MEAL became our metaphor for feeling safe and loved. CHEWING THE DAY became our metaphor for letting in joyful experiences. Beth tentatively revealed to me that she was actually obese and was using food in an addictive and unhealthy way. She was considering bariatric surgery, which she felt was the only option to improving her life, and to losing 125 lbs.

Beth’s revelation stunned me. I realize I had been treating Beth under “the illusion of absolute attunement” that holding affords. Slochower (1996). As the analyst mother, holding Beth in our phone sessions, I suspended my own experience. I was certainly an antidote to her own intrusive mother, believing that I was able to deeply “see” Beth.

But, what if, I wondered, I had been able to be in her actual physical presence in a traditional office setting or even via video? Would I have been able to hold her, or at least to have the illusion of absolute attunement? I have to admit that it would have been much more difficult for me to “see” Beth in the way I believed I came to see her in our second year of tele-therapy. Would my own history of struggling with weight have gotten in the way? I uncomfortably conceded it would have.

Beth’s surgery itself became a metaphor. We talked about Beth’s wanting to lose her mother’s weight, literally. Beth, who had always been too much for her mother, now realized her mother was too much for her. Making the decision on her own, to have the surgery, without telling her mother, Beth would shed her mother, and the 125 pounds her mother weighed. (I did not disclose that my own issues with weight also evolved in relation to my own overweight mother, as I struggled to understand the meaning of my countertransference).

It would be another anniversary of her father’s death before she actually had the surgery. In that time, our relationship experienced a significant rupture.

I was graduating from my analytic training and would be leaving NYC. Anticipating my departure, I had begun months ago terminating with patients. Because Beth and I met by telephone, I assumed our sessions would remain unchanged by my move. I was greatly mistaken. I mentioned that I’d be moving, and I must have seemed too casual. Beth was deeply hurt and angry, and our relationship ruptured. I felt embarrassed that, once again, I was so unaware. Here was Beth, who despaired of having the response she craved, being treated as invisible. I may not be able to actually see her, but I could not treat her as if she was invisible. I viewed Beth’s confronting me as an important milestone for her in that she was able to know what she needed, and moreover, ask for it, too. My moving created distance between us that I mistakenly thought could be bridged by technology.

I was uncomfortable and humbled, but my view of her strength in voicing what she needed helped me take responsibility. In my hope of repairing the rupture, I suggested we have another session before I moved. She declined saying that now that her operation was scheduled, she would be looking forward to that, and she’d be fine. I reached out again on the anniversary date- of her father’s passing, of her treatment with me- to wish her the best for her surgery. I left a voicemail but did not hear back.

Four months later, with my home office moved, I again reached out to Beth to touch base. She answered my call. The bypass operation had been a success, and she’d like to resume our sessions. We scheduled a time, and she asked if we could switch to Skype. Transitioning from years of audio-only to video is a significant shift in the therapeutic frame, and here it may have also represented a repair to our painful rupture. She was ready to be seen in a new way.

I felt anxious, anticipating our first Skype session. We were like a couple who had been dating online, had taken a pause, but never to actually see the other… now, the in-person blind date.

I can only say that first video session was unforgettable… like reuniting with a close friend one hasn’t seen in a very long time. After a few minutes acknowledging our pause, we picked up where we had left off, now with each of us receiving the other, a mutual knowing. When she asked if in our next session we could introduce our cats to each other (we had often talked about our beloved pets), I felt a twinship transference that was new. I now realized that the earlier rupture represented a sudden de-idealization of me that left her feeling unseen and uncared for. And prior to the de-idealization rupture she experienced, I felt self-conscious and mis-attuned in her obesity revelation; perhaps unconsciously influencing how I missed the implications of my moving, and that a more empathic attunement was needed.

Through the years of audio sessions, Beth spoke lovingly of her cat, Bozo- the one mutually supportive relationship in her life. I spoke also about my cat, Sammy, and we shared cat stories. In the next Skype session, we held Bozo and Sammy to the screen to meet each other. Together we embraced them, literally mirroring each other. Here were we both, now the good-enough mothers.

Beth continued in treatment for another two years while she successfully completed school and transitioned her career. We continued to include Bozo and Sammy now and then in mutually attuned twinship.

To conclude, I am grateful for Beth’s developmental and professional progress. But, equally as important, I am grateful that because of Beth, I developed a deeper understanding of my own blind spots, and how letting Beth determine our tele-therapy proximity was central to her successful treatment. I came to appreciate that tele-therapy can be just as successful, and is affected by the same factors, as in-person sessions. Even more importantly, I understand that treating remotely necessitates an extra measure of conscious effort to achieve the same level of empathic attunement.

Slochower, J. (1996) Holding and The Fate of the Analyst’s Subjectivity. Psychoanalytic Dialogues, 6:323-353

Togashi, K. (2008) A New Dimension of Twinship Selfobject Experience and Transference, International Journal of Psychoanalytic Self Psychology, Vol.4(1)