Therapeutic relationship on the web: to face or not to face?

Relação terapêutica na rede: to face or not to face?

Abstracts

In this age of unprecedented expansion of media and information dissemination and sharing, the use of electronic means should be reconsidered. The use of new technologies should be studied to understand how it may affect the relationship between patient and therapist during psychotherapy or psychoanalytic treatments. This study offers a critical discussion of the effect of technologies on clinical practice, and vignettes are used to describe their impact on frame, anonymity, abstinence and therapeutic neutrality. Transfer and countertransference issues resulting from these changes are also discussed. The potential benefits of new technologies in psychotherapy are appreciated, but the authors draw attention to the need to reflect about the presence of the therapist in those technologies and the preservation of the therapeutic setting, so that a satisfactory progression of the work of the dyad is ensured. This study also discusses the use of technologies in the expansion of learning and application of the therapeutic technique to overcome geographic and time barriers, among others.

Psychoanalytic therapy; Internet, social media; computer communication networks

Na era da expansão sem precedentes dos meios de comunicação, da divulgação e compartilhamento de informações por meios eletrônicos, torna-se necessário repensar sua utilização. Os autores consideram importante compreender de que forma o uso das novas tecnologias pelos pacientes e terapeutas interfere na relação entre ambos na vigência do tratamento psicoterápico ou psicanalítico. É proposta uma discussão crítica acerca de sua influência na prática clínica, e apresentado em vinhetas o impacto no enquadre, no anonimato, abstinência e neutralidade terapêuticas. Também são abordadas questões transferenciais e contratransferenciais decorrentes dessas mudanças. Os autores consideram os benefícios potenciais das novas tecnologias na prática psicoterápica, alertando porém para a necessidade de reflexão a respeito de sua presença nas mesmas e de preservação do setting terapêutico, visando sempre a evolução satisfatória do trabalho da dupla. Outro aspecto considerado neste trabalho é sua utilização na expansão do aprendizado e aplicação da técnica psicoterapêutica, superando, entre outras, barreiras geográficas e temporais.

Terapia psicanalítica; internet; rede social; redes de comunicação de computadores

Introduction

We live in an era of digital technologies under intense development. Among the many diverse inventions and advances, the Internet undoubtedly has the greatest impact on the different spheres of our lives, in both collective and public settings and individual, private situations. Technology has made possible so much that was unimaginable in the past. Different possibilities of communication, as well as new interpersonal arrangements, have developed along the path of enthusiasm created by a society undergoing change. Terms such as hypermodernity, supermodernity and liquid modernity have been created in an attempt to name an increasingly individualistic society centered on characteristics such as speed, quantity, consumption, instantaneity, movement, fluidity and globalization.^{1 - 3}

According to the creator of the term hypermodernity, the French philosopher Gilles Lipovetsky, globalization has greatly shaken social and individual ideals, firmly consolidated in earlier times. Because of the dissolution of hierarchies, the hypermodern individual has experienced a loss of references and, consequently, seems to now live in certain confusion in face of the innumerable alternatives that have developed. According to Lipovetsky & Charles,³ "what defines hypermodernity is not exclusively the self-critique of modern institutions and forms of knowledge, but also revisionary memory, the remobilization of traditional beliefs and the individualist hybridization of past and modernity. It is no longer a question merely of the deconstruction of traditions, but their use without institutional brakes, being perpetually reworked in accordance with the principle of individual sovereignty." In turn, supermodernity, characterized by figures in excess, has renovated the concepts of time, space and individual. The new concept of time takes shape in the acceleration of history based on the reality of information excesses to which we are exposed today.¹ Finally, liquid modernity refers to the idea of the inexact form of liquids: they take the form of the vessel that contains them. This fluidity would, at last, give rise to a world of uncertainty.²

Akhtar⁴ suggests that the impact of the Internet on our lives has three main facets: bringing external reality closer, permitting freer expression to the internal world and enhancing communication. At the same time that it provides access to information from all over the world, the Internet also creates the possibility of flow in the opposite direction. Our most intimate contents, thoughts, opinions and fantasies have also found a way of immediate and unrestrained expression on the Internet. Sociologists, as, for example, Bauman² and Castells,⁵ have written essays about the changes that new technologies and cyberspace produce and reproduce in human bonds and interpersonal communications. Cyberspace, the union of cybernetics and space, a term coined in 1984 by William Gibson,⁶ a Canadian science fiction writer, has been defined as the universe of digital networks that makes us aware of the geographic mobility of information, usually invisible.⁷

Several options and attempts have been made to understand such phenomenon. In any case, we should fundamentally understand such changes as results of a complex relation between social and individual factors comprising familial, inter- and intrapsychic elements that relate to each other dynamically. Inevitably included in this process, we perceive its reverberations as it directly or indirectly reaches our offices and influences, at variable degrees, the therapeutic relationship that we establish with our patients. Therefore, we believe that we, as therapists, should address this debate.

This study discusses the challenges that the advent of the Internet has created to therapist anonymity, abstinence and neutrality, including the new forms of communication between patient and therapist and the issues associated with the use of cell phones, texting, emailing and social networks. It also offers reflections on repercussions on teaching and supervision of psychoanalytic psychotherapists facing these new possible forms of communication.

The web and its controversies

Different positions have been taken on the influence of the use of the Internet, particularly of social networks, on the lives of people. Such diversity of opinions reveals that this matter remains complex, on shaky ground, and requires further discussion and more detailed analyses. However, human subjectivity has an unquestionable power to adapt and move into new contexts.⁷ Although the psychological and emotional consequences are not yet available for more consistent understanding, the use of social networks seems to have become inevitable in the relationship between therapist and patient and in treatment, either psychoanalytic psychotherapy or psychoanalysis, as illustrated by the vignettes presented below.

Scharff,⁸ for example, defends that analyses of the 21st century, when individuals live in a global economy and are capable of instant communications and easy travel around the world, have changed us both socially and personally and now define the need for adaptation of the work of psychoanalysts. According to that author, psychoanalysts should find ways to transcend the limits of distance and reach out to these contemporary analysands. Some possible solutions may be to reduce or condense the frequency of sessions or to travel for visits. Another way to preserve the frequency of sessions, described by the same author, would be voice communications using the phone or the Internet and also including the use of video cameras. According to the author, the practice of teleanalysis using the telephone and the Internet is increasing in response to the greater mobility of the population.

At the same time, Bauman⁹ sees social networks, namely Facebook, as tools that promote the lack of commitment to the idea of permanence and durability of personal relationships. According to that sociologist, virtual contacts have become very attractive to numerous people because they are easy and less risky than real, face-to-face contacts. In other words, online relationships may be easily established: it is enough to add a contact and instantly start counting an unlimited number of new "friends." However, the irresistible appeal of this new relationship lies especially on the fact that it may be discarded and disconnected at any time without complex explanations and with no justifications, condemnation or guilt. In this sense, Bauman believes that this dynamics generates important impoverishment of human bonds and may culminate in the feeling of being a solitary in a crowd.⁹

In face of this context, questions have been raised about whether hypermodern patients are able to tolerate doubt, wait and uncertainty about the result of psychoanalytic psychotherapy. For psychoanalysis and psychoanalytic psychotherapy, there remains the challenge of providing treatments that respond to the needs and angst of contemporary individuals, but which are not against the tides of current times.¹⁰ Another challenge to be faced by therapists is the fact that they are individuals that participate in the same psychosocial reality.

A sensitive issue, in which the use of the so-called new technologies may pose risks, is the preservation of the therapeutic setting. The possibility of finding and getting immediate access to therapists by means of information about their private life available on the Internet, for example, may rob the therapeutic relationship of its characteristics and affect the design of the therapeutic setting. However, Kowacs¹¹ points out that in psychoanalytic treatment, the setting is continuously threatened and rebuilt, and that these are movements that allow for the progression of the therapeutic process. Scharff⁸ agrees that the use of technology for psychotherapy may be a creative solution, but raises questions about the viability of the frame in preserving the setting and the therapeutic alliance and their effects on the emergence of resistance, non-verbal unconscious communication and the development of the analytical process. Questions have also been raised about whether the use of technology may lead to a dilution of psychoanalysis or if this adaptive innovation is clinically efficient and abides by psychoanalytic principles.

As psychoanalytic psychotherapists, therefore, we no longer have the power to remain only as spectators of changes within our traditional spaces. As all of us now leave "digital fingerprints," several issues are raised: How should a therapist behave when a request to add a friend is made by a patient in a social network? Under which circumstances is the interaction by electronic means with a patient acceptable? What happens to the privacy of a therapist that joins social networks? What is the impact of patient access to the therapist's life on their relationship? Should the therapist search for information about a patient's life on the Internet? Below we describe some fictitious cases based on our clinical practice to illustrate situations similar to those that occur in our offices today.

Clinical vignettes

Vignette 1

A 50-year-old woman undergoing psychotherapy for 2 years recently bought a tablet. She has regularly brought it to the office and, in the last minutes of each session, has shown family photos to the psychiatrist.

Vignette 2

An 11-year-old patient brings a videogame to the session and, as he does not have his own access to the Internet, asks the psychotherapist for the office's Wi-Fi password to play online. The therapist gives it to him, and the patient plays during the whole session. The therapists tries some interventions about the patient's difficulty in participating in the session. The patient goes on playing and does not respond, but the online connection is lost and the patient complains by swearing, says he does not want to stay and leaves before the end of the session.

Vignette 3

A 17-year-old adolescent patient finds out, before his next session, that his therapist uses WhatsApp in his cell phone and sends him a message together with photos of his High School Aptitude Test grade report (in Brazil, Exame Nacional do Ensino Médio, ENEM) and the list of the courses to which his score allowed him to apply for. In the message, he asks for the therapist's opinion and mentions feeling anxious.

Vignette 4

A 40-year-old man undergoing psychotherapy for one year and a half finds his therapist on Facebook and sends her a friend request. The request is turned down and the patient does not mention the fact in the next few sessions. He starts missing some sessions without previously warning the therapist. The therapist brings the topic up, examines the reasons for missing sessions, why the patient did not verbalize anything about the communication via Facebook during the session and the purpose of that request. The patient says he feels closer to her and supported by her, who he counts on as a friend. However, he says he felt rejected when the therapist turned down his friend request in the social network and considered discontinuing the treatment. The two, then, draw a parallel with the patient's failed relationships.

Vignette 5

A 31-year-old patient undergoing psychotherapy is often late for sessions. He did not resume treatment after the end of the year interval. The therapist unsuccessfully tries to reach him by phone for several weeks. He then searches for the patient in social networks and gets in touch with him there. The patient responds immediately and asks to make an appointment. The therapist calls, and they make an appointment. On the day before, the patient uses the social network to confirm the appointment time, and the therapist responds using the phone. During the session, the therapist explains that he exceptionally used the social network only because he did not get any answer to his phone calls. Weeks later, the patient misses another session and again uses the Internet to send an explanation. He asks the therapist's phone number in the Internet ("I believe I have the wrong number"). The therapist gives him his number, the patient calls and confirms the next session. During the session, the therapist again brings up the use of the Internet and says that he does not receive messages sent by the Internet as easily as those that he receives on his landline or cell phone. The patient says he understands, but justifies the use of the Internet because of his confusion and because he was in a hurry.

Vignette 6

An adult patient with psychotic symptoms has been undergoing psychoanalytical psychotherapy for five years. He begins the session telling that his mother is a famous actress that acted, during her youth, in films and plays in which she appeared naked. The patient is disorganized, anxious and expresses a mixture of idealization and shame in relation to his mother. The therapist suspects that it may be a delirious thought, as in five years of weekly meetings, this information about his mother had never been reported by the patient or his family members, who were called for interviews at times when the patient was very disorganized and his functioning was seriously impaired. The patient assigned his difficulties in relationships to his mother's exposure, as if everybody would instantly know about their family ties. His speech during that session was grandiose, fragmented, paranoid. The therapists perceives transference components in his report: the patient constantly sees women as idealized and persecutory objects; in previous sessions, the therapist had been accused of pretending to be interested in him, of being seductive and vulgar, which made the patient feel ashamed and made him avoid telling other people that he was undergoing treatment. The therapist wonders whether she should interpret those contents at that time, whether she should deal with that report as a psychotic symptom (acute positive symptoms had already appeared at other times during psychotherapy) or whether she should acknowledge the value of the fact that the patient had been able to share a family secret. She also asked herself to what extent the fact that the report was, or was not, true would make a difference in her listening. After that session, the therapist decides to check the information on the Internet and confirms it in several sites: information about the patient's mother, physically very similar to him, was found on the Internet and confirmed his report.

Novel forms of communication: the challenges to the psychotherapist's anonymity, abstinence and neutrality

Online social networks involve sharing interests and activities based on a virtual space and made available in various digital platforms. Freud¹² believed in the analyst's abstinence, neutrality and anonymity as crucial tools to achieve the therapeutic objectives. This premise is challenged by so much information about patients and therapists available today, which may easily gratify desire and confront fantasy and reality, although virtually. Therefore, the use that a therapist makes of communication and exposure means, such as the Facebook, remains highly controversial in the psychotherapy milieu.

A study of 400 physicians in France by researchers in the Rouen University Hospital¹³ found that most physicians defended the use of the Facebook by healthcare professionals. The interviewees believed that they should keep a private profile in the social network, but changes may occur in the physician-patient relationship when patients find their doctors in the Facebook.

Results are similar among American psychiatrists. Ginory, Sabatier and Spencer¹⁴ studied a sample of 182 psychiatry residents of the APA (American Psychiatric Association) to evaluate their behavior in social networks. They found that 89% have or had a Facebook profile. Of those, 95.7% had a Facebook profile at the time of the study and 12.3% had an open profile. The authors reported on some information found in the residents' profiles: 35.5% used to post comments about their residency, 11.6% posted information about specific patients and 1.9% posted patient photos in their timeline. Of all interviewees, 9.7% had already received Facebook friend requests from current patients, and none accepted them; 3.9% received friend requests from former patient, and only one accepted it. No resident had ever sent friend requests to patients. When asked how they would turn down a request, 14.2% of the residents would refuse a friend request from a patient only after discussing it with the patient personally, and the others would refuse it right away. Interviewees were also asked about the use that therapists make of social networks as a support to treatment: 18.7% of the residents said that they had already searched for the profile of a patient in the Facebook out of curiosity, to check information, to follow up progression after discharge or to investigate evidence of suicidal ideation. A resident reported having received a suicide message from a patient in Facebook and contacted the police to check on him. When asked about the study of this matter, only five residents reported having discussed the use of virtual relationships in their training programs in psychiatry. Most did not know of any literature about it.

The questions about the therapist's position in face of these situations led to the development of guidelines by the American Medical Association¹⁵ to preserve professionalism in social media (Table 1). Gabbard et al.¹⁶ have also made recommendations for psychiatrists about how to behave in social networks, shown in Table 2.

Table 1
Guidelines of the American Medical Association for the preservation of professionalism in social networks

- Physicians should be cognizant of standards of patient privacy and confidentiality that must be maintained in all environments, including online, and must refrain from posting identifiable patient information online.

- When using the Internet for social networking, physicians should use privacy settings to safeguard personal information and content to the extent possible, but should realize that privacy settings are not absolute and that once on the Internet, content is likely there permanently. Thus, physicians should routinely monitor their own Internet presence to ensure that the personal and professional information on their own sites and, to the extent possible, content posted about them by others, is accurate and appropriate.

- If they interact with patients on the Internet, physicians must maintain appropriate boundaries of the patient-physician relationship in accordance with professional ethical guidelines just as they would in any other context.

- To maintain appropriate professional boundaries physicians should consider separating personal and professional content online.

- When physicians see content posted by colleagues that appears unprofessional they have a responsibility to bring that content to the attention of the individual, so that he or she can remove it and/or take other appropriate actions. If the behavior significantly violates professional norms and the individual does not take appropriate action to resolve the situation, the physician should report the matter to appropriate authorities.

- Physicians must recognize that actions online and content posted may negatively affect their reputations among patients and colleagues, may have consequences for their medical careers (particularly for physicians-in-training and medical students), and can undermine public trust in the medical profession.

• Based on McMahon.15

Table 2
Recommended guidelines for maintaining professional boundaries online(16)

- Psychiatrists and other mental health professionals who use social networking sites should activate all available privacy settings.

- Web searches should be conducted periodically to monitor false information and photographs of concern. If these items are discovered, the website administrator can be contact to remove problematic information.

- The following items should not be included in blogs or networking sites: a) patient information and other confidential material; b) disparaging comments about colleagues or groups of patients; c) any comments on lawsuits, clinical cases of administrative actions in which one is involved, because they can potentially compromise one's defense. and d) photographs that may be perceived as unprofessional (e.g., sexually suggestive poses or drinking/drug use, etc.).

- Although looking up information about a patient on the Internet is not unethical because it is public, psychiatrists who choose to do so must be prepared for clinical complications that require careful and thoughtful management. Some patients may experience the psychiatrist's interest in this information as a boundary violation or a compromise of trust.

- One should avoid becoming "Facebook friends" or entering other dual relationships with patients on the internet. One strategy is to have separate profiles for separate roles, that is, personal versus professional.

- One must not assume that something posted anonymously on the internet will remain anonymous, because posts can be traced to their sources. Psychiatrists or psychiatric residents who wish to post their availability on online dating sites are free to do so, but must be fully prepared for the possibility that patients will see them and have strong reactions.

- Training institutions should educate their trainees about professionalism and boundary issues as part of their professionalism curriculum and assist them in their mastery of technology.

- All training institution should develop policies for handling breaches of ethics or professionalism through internet activity. Psychotherapy training should include considerations of the clinical dilemmas presented by social networking sites, bogging and search engines, as well as potential boundary issues.

• Based on Gabbard et al.16

Despite the growing acceptance of the use of new technologies by professionals, some psychoanalysts suggest that the meaning that their use might have in the therapeutic relationship should be carefully examined. Lisondo,¹⁷ for example, questions whether psychoanalysts and psychotherapists are not being submitted to post-modern demands without reflecting and searching for the meanings of human behaviors, and clarified their position when they affirm that psychoanalysis faces the challenge of investing against immediacy, the lack of reflection, the anti-insight, the feelings of nothing to desire and the loss of ideals. She concludes by saying that new technologies may be facilitative under exceptional and provisional circumstances of the analytic encounter, but they may be an obstacle because of the limitations that they establish as they impoverish and distort the essence of psychoanalysis. Analytic work should be nourished, reinvigorated and strengthened, and never perverted.

Undoubtedly, cultural and technological advances have brought new possibilities to communications and, consequently, to the construction of bonds between individuals. Changes in the way that we relate to time and space and in the way that we use language have now reached the analytic setting. According to Levy,⁷ this process is not new, but, rather, a continuum, because digital advances enable communications to continue their movement towards virtualization, which started a long time ago with the oldest techniques, from writing to sound and image recordings and the radio, the television and the telephone.

Kowacs¹¹ points out that the aspects of this new technological reality affect the setting and the dyad relationship, and may also affect the internal setting of therapists or analysts. The author, therefore, recommends the use of negative capacity,¹⁸ which makes it possible to accept non-knowledge, such as the questions about the maintenance of framing in this new context. The instant satisfaction of curiosity on the Internet feeds fantasies of omnipotent control by the patient using the virtual invasion of the therapist's life. Feelings of exclusion and abandonment temporarily cease to exist. Limits are abolished, and gratification is immediate. However, the author argues that the use of telephone, internet and other means of distant communication enable the maintenance of the patient-therapist alliance established face to face in the case of prolonged travels, disease and certain types of professional activity. These resources make it possible to give continuity to the therapeutic process. The task of the contemporary therapist is, therefore, to increase setting flexibility without losing its essential characteristics.

How to buffer the impact of change and keep ethics and quality in analytical work? We believe that, if the external setting becomes more flexible, the therapist should preserve it intact internally by keeping the capacity to deal with the transference signs instrumented by technology, as well as with neutrality, abstinence and possible anonymity.

The understanding of the dynamic unconscious, the cornerstone of psychoanalysis, has not changed, despite all the current technological armamentarium. A solid framing anchored in psychoanalytic theory and good practice enables the dyad to understand and interpret new situations according to psychoanalytic theory.¹¹ When the therapeutic setting is preserved as the guardian of the analytic process, changes may be carefully controlled to avoid that they block the advancement of understanding and the meaning of the process itself. According to Lisondo,¹⁷ elasticity demands permanent mental work and self-observation, so that the alliance in not lacerated or disfigured.

Despite all the elasticity so far incorporated into the therapeutic setting, not all authors are in favor of the changes discussed here. Lisondo¹⁷ actively criticizes new technologies in analysis and psychotherapy and claims that these resources tend to prevent patients from reaching primitive mental states that are accessible and visible in reality, through preverbal and verbal language according to Freud's second topography, but not in virtual reality. According to the author, in telephone treatments, the access is limited to the verbal level; in those via Skype, the lower body and the environment are not seen; and webcams and VOIP do not ensure good overall perception. The author also claims that it is in the access to these states that lies the origin of human representations and symbols to be achieved in adult life, and gives the example of non-neurotic patients, who need an intimate face-to-face relationship in which sensorial signs may be dreamed, intuited, understood and transformed by the analyst. The same author wonders what happens, when computers are used, to the contemporary concepts that invest intensively in the therapeutic relationship, that is, third analytical, analytic field and intersubjectivity, which construct the fine and delicate affective tuning.

According to Trotta,¹⁹ the individual involved in a virtual analytic process may develop omnipotent fantasies of sidestepping time and space or, in other words, sidestepping the principle of reality. Such questions stress the need to be careful when using technologies for psychoanalytic techniques, so that the perception of professionals are not hampered when doing their work.

Novel forms of communication: changes in teaching and psychotherapist supervision

In face of these novel forms of communication, psychoanalytic psychotherapy teaching is also an expanding field, and several new forms of teaching and supervision using virtual reality may be suggested. Therefore, a new challenge arises: how to incorporate new technologies and at the same time preserve learning of the technique when sharing knowledge with students and supervisees? Using the technology available to supervision, Abbas et al.²⁰ studied supervision by web-conference motivated by its ease of use and because it may be conducted over distances that limited the learning process between supervisors and students in the past. Those authors believe that inexpensive, widely accessible Internet-based training methods seem to offer a wide range of benefits and few limitations. Although further studies are necessary, they suggest that the web-conference supervision model may become the central vehicle of global dissemination of psychotherapy skills.

Distance supervision is not a novelty, as it was first conducted by Freud by means of his correspondence with Fliess, which may be compared with today's emails. However, is it a modality open to errors and communicative problems due to the limitation of access to the nuances of verbal and body language.

Gavião et al.,²¹ who conducted a group seminar about counter-transference condensed into two face-to-face meetings and further discussions by email, wrote about and discussed their innovative experience. In 110 email messages, the seminar theme was developed at the same time as participants appropriated the use of the Internet as the space of the teaching model used to think about psychoanalytic clinical practices. By means of electronic dialogs, the group was able to examine their own contradictions about the psychoanalytic setting: real vs. virtual, presence vs. absence, connection vs. disconnection, exposure vs. hiding, proximity vs. distance and communication vs. confusion.

When analyzing dynamic psychotherapy teaching and supervision experiences that follow technological innovations and may use them, useful and productive results seem to be confirmed. Technology, in all cases, has been used to reduce distances and spread knowledge without, however, abandoning the fundamental principles of psychoanalytic techniques or neglecting confidentiality and all other ethical issues that this activity requires. Moreover, relational issues between supervisor and students should remain important, whereas the possibility of working without face-to-face contacts between them has never been recommended.

Final considerations

The inclusion of new technologies in the setting of psychoanalytic psychotherapy seems to be greatly controversial. Online treatments, for example, may also be controversial, although they may potentially help patients that would otherwise not have access to face-to-face psychotherapy due to geographic distance, difficulties in locomotion or fear of changing psychotherapists. In Brazil, the Federal Council of Medicine (Conselho Federal de Medicina - CFM) prohibits virtual medical consultations to substitute for face-to-face encounters with patients, as described in the CFM Resolution 1974/2011 (Section 30).²² In contrast, the Brazilian Council of Psychology (Conselho Federal de Psicologia - CFP), in its Resolution 011/2012, does not prohibit it, but recommends that psychotherapy conducted by means of technological resources for distance communications should be exclusively experimental (Chapter I, Section 10 and Chapter II, Section 90).²³

In current clinical practice, the undeniable and irreversible presence of new technologies at different degrees of complexity and of use by patients and therapists requires that therapists should adapt rapidly and continue questioning its use. The vignettes described above seem to indicate that there are no differences between showing a conventional photo album to the therapist or bringing it to the session as digital photos in a tablet. The meaning of the act alone does not change just because the means used to perform it has changed. When the patient with the videogame continues playing online during the session, would it not be only a new, perhaps more disturbing because unusual, form of the old, familiar resistance? When possibly placed in the position of the third person, the one excluded, the therapist might feel cheated and left alone by the patient. Still, in the same scene, the patient may be telling the therapist something that still cannot be understood as his own. In the case of the patient in vignette 3, the technology available seems to favor the overflow of the patient's anxiety through easy and continued access to the therapist. Maybe, before the existence of WhatsApp, this same patient would leave innumerable messages in the office's answering machine and would also call the therapist's home. Would the therapist's interpretations be very different in either case? Again, resistance and transference issues are clear when the patient in vignette 4 sends a Facebook friend request to the therapist, trying to move her out of her position and making her a "friend," and when avoiding discussing the request and the subsequent feelings about the fact that the therapist did not respond to that request. In the same way, in vignette 5, the "failure in meeting" between therapist and patient and the different understandings of how to get in contact illustrate the confusion of transference and countertransference in the therapeutic process. In this vignette, the therapist used the network to get in contact with the patient, the same network that the therapist in vignette 6 uses to decide whether what his patient reported during the session was a painful revelation of a family secret or a delirious idea that should only be dealt with as a manifestation of the patient's inner world.

The basic concepts of psychoanalytic theory have proven, as seen here, to be extremely useful to understand the changes in the ways to express feelings and communicate ideas between patients and therapists. Technology and psychoanalysis have the same prerogative: to build bridges between contents, lives, people and techniques. Oliveira²⁴ points out that it is necessary to effectively find out how this range of basic psychoanalytic concepts operates in this new environment. Based on the considerations above, we believe that the use of technology, in addition to providing a new packaging for old issues, provokes effective transformations in the psychoanalytic psychotherapy setting, and it can no longer be separated from the clinical work conducted in the office. Technology does not seem to change the essence of the work conducted in psychodynamic therapies, but is an instrument of inclusion and accessibility, as long as its use is guided by well based psychoanalytic rules. Therefore, therapists should try to understand the meaning of what is happening in psychotherapy at the same time that they evaluate their own behavior, be it more or less active, in respect to the use of new technologies. Regardless of the form that therapists choose to deal with the use of technology in the clinical practice, they should identify whether it is an increase of communication between patient and therapist, a bastion, an expression of resistance, a difficulty of countertransference or an enactment, among other possibilities.

As psychoanalytic psychotherapists, we have to accept the advances brought by the passing of time and be open to constant innovation, as well as willing to face possible disillusionments at contemporary society. At the same time, we need to recognize the suffering and the symptoms that emerge in this contemporary form of subjectiveness. We should promote constant reflections about these generational differences.¹⁰ We face significant and unquestionable advances in human relations, as so many times before in history. Because of these changes, research and studies in this area should continue carefully and spurred by curious learning, so that clarity, integration and progress are maintained, instead of obscurity, fragmentation and regression.

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• Suggested citation: Sfoggia A, Kowacs C, Gastaud MB, Laskoski PB, Bassols AM, Severo CT, et al. Therapeutic relationship in the web: to face or not to face? Trends Psychiatry Psychother. 2014;36(1):3-10.
• Financial support: none.

Publication Dates

• Publication in this collection
  Jan-Mar 2014

History

• Received
  13 Oct 2013
• Accepted
  23 Jan 2014