NEW YORK -- As some analysts become
comfortable with the notion of "the chair," instead of "the couch,"
others are welcoming yet another setting: the computer screen.
Though it may be controversial among
the conservative clinicians, researchers have been using a popular
online video chat program known as Skype to reach faraway patients,
particularly those in China.
Ubaldo Leli, MD, an analyst in private
practice in New York City, is vice president of the China American
Psychoanalytic Alliance (CAPA), an organization that treats patients
and trains mental health professionals in China.
At a session at the American
Psychoanalytic Association meeting here, Leli said he conducted his
first Skype analysis with a Chinese patient in 2004.
"When I did my first Skype analysis, I
had many doubts," he said. "Will the analytic process develop? Will
there be language differences? Cultural differences?"
He soon began to feel that the Skype
analysis was "similar to any type of analysis." He recalled one
Chinese patient who was seated on his own couch in his own living
room, with his computer (and hence, Leli on video chat) behind him,
as in a typical analytic setting.
"He was talking, and then he stopped,
and I asked him why he stopped," Leli recalled. "He replied that he
sensed a change in my breathing and thought I wanted to say
something."
The popular Skype software (available
at skype.com) is
a free download that allows users to make free voice or video calls
(if both sides are equipped with Web cameras) anywhere in the world.
The company also provides low-cost long distance calls between Skype
users and standard local phone customers. Other programs provide many
of the same features.
Although Skype can create a sense of
connectedness, Elise Snyder, MD, an analyst from New Haven, Conn.,
and president of CAPA, said it "simultaneously provides intimacy and
distance." Patient and analyst are in separate spaces, and are often
divided by many hours -- about 13 with Chinese patients.
And it introduces issues of language
and culture that are not typically present in analysis. Snyder said
these are "not insurmountable, but they are present."
Lana Fishkin, MD, who is on the board
of directors of CAPA, said from a cultural standpoint, sex is often a
troublesome issue in remote sessions. While discussion of sex is a
usual component of analysis in America, it's rarely mentioned among
Chinese patients.
During analysis, Fishkin said she's
"hesitant to point out that it's absent, because I'm not sure what it
means in Chinese culture."
She also called attention to
differences within the Chinese culture itself. "There have been huge
changes over just one generation in China that both we and they have
to deal with," she said.
Ralph Fishkin, DO, who is also on
CAPA's board, said language issues can be tricky as well. "You have
to pay more attention to the word the person uses and what exactly
they mean by it," he said. "You have to ask yourself if you're
precisely understanding their feelings."
He added that the process of analysis
itself is different in the context of Skype: "You're in your room,
they're in their room. It's like making a house call at the same time
the patient is coming to your office."
Some audience members at the session
pointed out that there's no data on the subjective impact of the
"space" that patient and the analyst are in. They also questioned the
analyst's ability to maintain perfect eye contact with the patient,
as well as the potential to pick up on other body language that would
be perceived during an in-person session.
Yet one of CAPA's goals is to train
Chinese analysts so patients there can have one-on-one interaction.
Snyder said next year's class has 100 applicants, among whom 40 or 50
will be accepted to the program.
She noted that the "community
interested in analysis is small in China," which can create ethical
dilemmas. Shanghai may have 22 million inhabitants, but
psychoanalysts will be familiar with everyone in their community,
including patients.
"It does raise ethical issues in
confidentiality," she said. Psychoanalysis via Skype can also help
analysts keep in touch with patients who used to come to in-person
sessions but have since moved away -- although there are no data on
how many currently practice this type of remote analysis.
"Skype is only the beginning," Leli
said. "There are all sorts of new technological developments that
will modify the way we think about the analytic frame."
Primary source: American Psychoanalytic
Association meeting
Source reference: Snyder E, et al "Cross-cultural issues in analytic
treatment via Skype of Chinese patients" APsaA 2010. |
