Online psychoanalysis and psychotherapy

Approximately one hundred years later, videoconferencing technology became available to the general public, allowing therapeutic encounters to take place online. It is only relatively recently that this technology has become consistently reliable and of good quality.

Let us look at the differences between the two modalities, what we have learned about working online, and when it may be an appropriate treatment.

Since the beginning of psychoanalysis, physical presence has always been taken for granted in establishing the therapeutic relationship. For both participants, it conveys a sensory density rich in conscious and unconscious information about the other person, including simply the fact that they are physically there, which is indispensable for some individuals.

Likewise, the commute to the psychoanalyst's office and the feeling of being welcomed into a physical space—with its specific characteristics of light, temperature, sound, comfort, decoration, and smell—can take on great symbolic value, evoking significant elements of the patient's psyche and creating a place that lends itself to expressing and feeling certain things in a safe manner.

The relative importance of these characteristics of the setting will depend on each patient. For some patients they are fundamental, for others not so much.

The experience of pioneering colleagues, who began working with the possibilities opened up by technology as soon as it became available, as well as the exceptional conditions of the pandemic, which led almost all mental health professionals to work remotely, revealed to us that, in many cases, good psychotherapeutic and psychoanalytic work can be done online.

We discovered that, in addition to its undeniable logistical advantages, online work brings with it a whole series of specific variables whose impact on treatment must be taken into account. For example: what technology is used, with its advantages and disadvantages; the privacy of that technology; the place or places chosen by the patient for their session; what unconscious meanings the lack of physical presence has for the patient; the potentially different temporal, cultural, linguistic, political, geographical and climatic contexts for the patient and the psychoanalyst, etc. The psychoanalyst must pay close attention to these variables in order to understand their symbolic value for the patient and how they affect the therapeutic process.

Whether these variables, specific to online work, are primarily an impediment or a rich source of therapeutic information will depend largely on how the psychoanalyst listens to them.

It is noteworthy that some psychoanalysts have made the surprising observation that, on some occasions, the nuances of the patient's discourse are better heard when there is only the auditory channel of communication, without visual distractions.

Privacy, consistency and stability of meetings, and a quiet place, are the necessary conditions to create a framework that facilitates listening to the unconscious, allowing it to surface, be contained and understood. These conditions must be present both in in-person and in online work.

Therefore, when considering beginning psychoanalytic psychotherapy or psychoanalysis online, it will be essential for the psychoanalyst and the patient to agree on the establishment of the safe, stable and reliable conditions of the framework that will allow fruitful psychoanalytic work to take place. 

Before beginning online psychoanalytic or psychotherapeutic work, it is necessary to assess the reasons that lead to a request for remote treatment.

Sometimes it is essentially motivated by an inability to attend a psychoanalyst's office in person, either due to geographical distance or incompatibilities with available psychoanalysts. On other occasions, some requests also involve an unconscious need to maintain distance from others, and online work is the only way to begin to address that suffering. And sometimes it is a mixture of the two.

All of this will be carefully evaluated during the assessment interviews to establish the most beneficial treatment framework for the patient.

In cases where online work is indicated, experience also shows us that, as far as possible, some regular face-to-face contact between the psychoanalyst and the patient is beneficial to the process.