For the past twenty months or so I have been a participant in group-analytic psychotherapy. When I joined my group, in those unsuspecting and blissful days of January 2020, we met every Thursday evening in a rented room upstairs in an office building converted for the use of a range of therapeutic services. It takes a good while to settle into a group, but this was an opportunity, as my therapist suggested to me in our preliminary one-to-one sessions, to examine how I deal with new people, new social settings; it was a chance to think about what it’s like to be new or to do something unfamiliar. I was having trouble relating to other people, and when I got in touch with the man who is now my therapist to try and resolve this issue, he suggested I give the group a try. Unlike individual psychotherapies, group-analytic work involves receiving feedback from the other participants. Rather than working through the unconscious transference of your past relationships and emotional difficulties onto one person (the therapist), group-analytic work relies on its participants using and being used by everyone else present. In group you can yearn to win someone’s approval for months, only to eventually figure out that you’re just replaying the dynamic of trying to win your parents’ love as a child. Meanwhile, someone else might be using you as a way of exploring their anger toward their own children, their feelings of not mattering, of being forgotten. In group, you don’t just have one person onto whom you project your suffering, you have seven or eight, all of whom are projecting theirs onto you.
I went to six sessions in person. Around the fifth or sixth session a couple of people mentioned this virus that had been in the news a lot recently, which was looking pretty bad in Italy, but we didn’t talk about it much. Two weeks later, now in the first of the U.K.’s multiple lockdowns, the group started to meet through a conference-call platform. “These are unprecedented times,” our therapist reminded us, more than once. To his credit, he didn’t give us any insight into the anxieties he must have been feeling; he kept to his role as a predominantly silent figure, somehow both at the center of the group and outside of it. In group analysis, the therapist is called the conductor, meant both in terms of an orchestra and a material that can transmit heat or electricity: the conductor is someone who both organizes and mediates. But now there was another mediating function in the sessions, intrusively present and central to our conversation: the technology of the phone call. We spoke on the phone for a few months, before switching to the more controversial but increasingly ubiquitous medium of Zoom. The dynamics of the group were suddenly placed under new pressure, as we were forced to navigate the messiness of each other’s emotional lives from across what felt like a great, even insurmountable, distance.
The encounter between therapist and client is always mediated by a frame: the arrangement arrived at by the participants in terms of session frequency and length, cost, how payment is made, location, the layout of the consulting room, the use of the couch or chair and so on. All these elements must be negotiated and then discussed, worked through in the therapy, since they are often sites of complicated (and thus productive) feelings toward the therapist and the work the patient and therapist are doing together. Often the negotiation of the frame’s specifics takes place during the initial consultation between therapist and client and then stays for the most part consistent. In the case of my experience of therapy, and I suspect many others’, the pandemic has forced the details of the frame into view more or less constantly.
The frame, of course, has been historically flexible throughout the growth and adaptation of talking cures over the last 120 years. Freud initially worked on a basis of six sessions per week, with an analysis that often lasted less than a year; Lacan experimented with very short sessions, sometimes a matter of minutes; Christopher Bollas has written about occasionally holding weekend-long sessions for clients in acute crisis. Nowadays it’s typical for people to see their therapist only once or twice a week but over a number of years; it’s also common (here in the U.K. at least) for people to be offered a short course of six to eight sessions with an NHS therapist—if, that is, you make it to the end of the interminable waiting list.
This variation and expansion of the psychotherapeutic frame is a central concern of Hannah Zeavin’s timely new book, The Distance Cure: A History of Teletherapy (MIT Press), which examines the development of therapy-at-a-distance. Through a chronological examination of major moments in the history of psychotherapy, The Distance Cure argues for the centrality of distance (of one kind or another) to the therapeutic encounter, reframing our understanding of psychotherapy in order to draw attention to the inescapable fact of separation present in all therapies. Perhaps we habitually consider psychotherapy as somehow more effective if it takes place between two people meeting each other in a room, and we might imagine that the turn to video- or teletherapy during the pandemic would be inferior substitutes for the original format. Against this assumption, Zeavin’s book argues that the distance and separation of remote therapies have been present in talking cures right from their beginnings in fin-de-siècle Vienna. Rather than taking for granted the psychotherapeutic encounter as one that takes place between two individuals—analyst and analysand, therapist and client—in a shared physical space, Zeavin carefully examines the kinds of distancing mediation inherent in the very nature of psychotherapy. In Freudian psychoanalysis, as Zeavin points out, the use of the couch makes the analyst invisible to the analysand, introducing into the physical space of the consulting room the distance required for the fantasies necessary for transference to emerge and be worked with. “The removal of the body,” Zeavin writes, “allows unconscious work to occur on both sides of a communication.”
Well-researched and enormously confident with the materials at hand, The Distance Cure develops the concept of “distanced intimacy,” a term used by Zeavin to describe the specific form of human relation that is encouraged, created and maintained by therapies that take place through communication technologies, rather than in person. Distanced intimacy creates a feeling of self-protection by acknowledging the fact of distance, while also generating a feeling of intimacy that emerges through helping and being helped: it operates dialectically, Zeavin tells us: “on the one hand, it stipulates a distance it must then cross, while on the other it maintains that distance as a shield enabling safe disclosure.” This distance can be maintained through the anonymity of a helpline, for example, or through the ability to access an app or a therapy chatbot when you need it and then quit the session when you’ve had enough, or even through written correspondence (one of Zeavin’s earliest chronological examples of distanced intimacy is of the growth of intimacy and revelation in the self-analysis Freud, in Vienna, conducted through letters with Wilhelm Fliess, in Berlin). Zeavin aims to disrupt the notion that emotional contact made from a distance is somehow “lesser” than in-person encounters. Instead, she argues, the relationships between absence, distance and presence have always been at stake and up for negotiation in psychotherapy. Because of their explicit reliance on mediated distance, remote therapies offer a way for individuals to learn how to be in touch with the other across distance, to be with others even when alone. What’s more, the feeling of being unobserved, or of being anonymous, or of having the freedom to terminate the session on one’s own, may actually encourage a greater openness and honesty from the person seeking help.
But distanced therapies are not all created equal. While Zeavin tries to reassess and even defend certain forms of remote therapy, she is more critical of apps or chatbots, which risk turning therapeutic practice into a feel-good video game. This gets at one of the big questions Zeavin asks in The Distance Cure: How pleasurable should therapy be? In my experience of therapy there are certainly moments of pleasure, but they come along with moments of anger and boredom and sadness and grief and irritation and all the rest of it. I do not think of it as a pleasurable experience, but I take no little satisfaction from the ascetic and slightly puritanical idea that because I don’t enjoy it, it’s probably working (nothing enjoyable can be good for you, surely). By and large, psychodynamic psychotherapy is not an enjoyable experience, and will often make people feel much worse before they begin to feel better. This is not the case with the automated-therapy app. These apps, as Zeavin demonstrates, have been engineered to encourage user engagement by providing instant pleasure; they are gamified technologies designed to turn a profit in the booming business of mental health. Writing about Wysa, a Google-funded mental health app that tracks sleep and mood and offers a “cute, ‘cheer me up’ buddy” in the form of a penguin avatar, Zeavin argues that “enjoyability is intrinsic to intimacy with a nonhuman other because it is a way of being intimate with the self—even, or especially, if that self-intimacy is mediated by a digital penguin.”
Zeavin describes the client’s relationship with the therapist as an “as-if” relationship: one in which fantasy and the hypothetical are taken seriously and worked with; a relationship in which each party can make use of the other in a helpful way. In contrast, automated therapies that emerged out of cognitive-behavioral therapy rely on an “if-then” relationship: if this the problem, then here’s the solution. There’s less scope for complexity, ambivalence, contradictory feelings; there’s no room for interdependence. Follow the workbook, repeat the script, check in with your little penguin friend, and everything will be alright. This is not the same as the self-understanding that talking therapies offer. Freud famously promised that the best outcome of a psychoanalysis was a freedom from the trap of neurosis and a return to “ordinary human unhappiness.” It’s difficult to imagine this as a slogan of a CBT-based mood tracking app.
The Distance Cure describes a historical shift in psychotherapeutic techniques from the relational to the auto-intimate: from a process of becoming dependent on another person, your therapist, to one of becoming reliant only on yourself and your ability to do your homework and update your apps. Dependence, after all, can be terrifying; it can be agonizing and difficult and enraging. But it is also the nature of humanity to be dependent on one another, whether we like it or not. This is one of the major lessons of group work: everyone in the group has to come to depend on each other, whether we like it or not—and, more often than not, we do not like it. We may feel good about ourselves after tracking our mood, like we’re getting our lives in order, but is it really a substitute for sharing a space with other people and allowing ourselves to encounter and express the whole gamut of human emotion?
This is why, even though I wish it didn’t, my experience of group therapy through Zoom has felt, inescapably, like a compromise. As the prospect of returning to in-person sessions became more certain, the improvisations, inadequacies and limits of the remote sessions felt increasingly apparent. This might merely be some kind of fantasy, a desire for the pure encounter that takes place in a consulting room, but it’s a useful one, motivating my and my fellow members’ continued presence in the group. Why is it that, in principle, both options seem equally good, but in practice, in-person therapy just feels more effective?
When my group met in person, we all sat in chairs in a circle; we read each other’s body language, but we weren’t allowed to walk around the room. Nervous movement would be restrained to jiggling a foot, or scratching an itch. One of the other rules for behavior in the group is no drinking: taking a sip of water is a good way to temporarily escape from what you’re currently feeling. On the phone, freed from the observation of the group, I paced around the room relentlessly during the calls. I drank prolific amounts of water, which I would immediately sweat out. When you meet in person, a silence in the group can take on various valences, and it can take some time for these to clarify in the room. When you speak on the phone, a silence in the group immediately raises the question of abandonment: Is everybody still there? Can you hear me? Has anyone heard a single thing I’ve said? In one call, fairly early on in this new world, the battery in my phone ran out mid-session—I rushed to charge it and rejoin the call, panicking at the disruption I must have caused, the anxiety I’d induced in the others, who turned out to be largely unfazed when I returned, having guessed what had happened.
We spoke on the phone for some months, and then we eventually switched, like the rest of the world, to Zoom. There was a lot of discussion before this switch took place, interminably so at times. Some members left, abruptly, without saying goodbye. Other members did not leave but started to make noises about doing so. The question of inviting each other into our homes became fraught for some participants. Words like “invasive” were bandied about; shame was evoked every week. New members had joined, whose faces none of us had yet seen; we were just disembodied voices to each other. Some members struggled to persuade themselves they were ready for the switch to video, and they kept dialing in: a black box in the gallery, a sign of their feeling of exclusion from the group, their inability to allow themselves to fully participate. Eventually, after months of discussion, they joined the video calls—only to tell us they were thinking about leaving the group because recently they hadn’t felt able to fully engage.
When we started meeting through video calls, as opposed to the phone calls or in-person meetings, a new kind of intimacy began to blossom. We were closer to the experience of in-person sessions, but there was still a difference: the unavoidable fact that we were not all sitting in an anonymous consulting room with tastefully neutral decorations. We were all at home, in our bedrooms or spare rooms or home offices, interrupted by traffic noises outside, by housemates walking into the room, by a feeling of constraint stemming from a worry that we might be overheard by people we were living with. It’s difficult to talk about your relationship in therapy when your partner is two rooms away. New constraints developed. The frame had shifted, been destabilized, and become fraught. And, in the process, it became something to discuss, something to interpret or challenge or lament. In person, not drinking water was a quietly accepted rule; we didn’t discuss it, but nobody brought a water bottle with them. When we switched to Zoom we discussed whether or not it was acceptable now to drink anything in the sessions. The conductor suggested the usual rule should still apply, but every week, group members still sipped from mugs and bottles and tumblers, myself included. Something had been renegotiated. Zoom offered us a different kind of relation to the conductor’s authority, a different kind of relation to each other and to the group as a whole.
One of the differences between remote and in-person group work comes down to a common impulse (one that every participant in my group has confessed to): the urge to hide. In person, it’s hard to hide in a group. You can stop speaking, withdraw from what’s happening around you, but sooner or later your silence and disengagement will begin to take on a weight and texture that needs to addressed. Someone will ask you where you are. But on the phone it’s easy to hide: you just stop saying anything. Silences feel less like they belong to anyone in particular; they are the group’s silences. Over Zoom, confronted with each other’s faces again, there were new ways to hide: not turning your camera on, or sitting further back from it, even discreetly occupying yourself with something off-screen (one participant recently confessed to doodling during sessions, disengaging emotionally from the conversation and keeping their hands below the camera’s line of sight). The ability to hide, and a reluctance to call each other out on hiding, means that a kind of politeness has sometimes fallen over the group; we are concerned not to make each other feel too bad or guilty for our inattentiveness. Politeness is another kind of distanced intimacy, one which means we avoid conflict. This, in therapy, is unhelpful.
As Zeavin explores in her coda, the pandemic has caused a major change in the provision of mental health services. At the same time as forcing a near-universal migration to remote psychotherapy, the events of the past twenty months have resulted in an unmeasurable amount of trauma and psychic distress. Put simply, many more people now need therapy. Teletherapy and its history have suddenly gone from being a fairly niche issue in the history of technology to a major question about how to manage emotional and psychological responses to a major catastrophe. New forms of psychological therapies have often bloomed during crisis: group-analytic work itself emerged out of experiments at British military hospitals overrun with traumatized soldiers during the Second World War. At a time of mandated distance, remote therapy technologies have made these services more widely available. This is fortunate.
But despite Zeavin’s argument that remote therapy is not necessarily “lesser” than in-person work, my own experience of remote group therapy has quite often felt inadequate solely because of the distance involved in our distanced intimacy. Remote therapy, Zeavin writes near the beginning of The Distance Cure, is not just a way to work out how “to be with the other via time with a disembodied other; it is also a tool for developing the ability to tolerate being alone.” Learning how to tolerate being alone is certainly an important part of life, but it is not a goal all therapies share. Many participants in my group—myself included—choose to attend this particular kind of therapy because they struggle with being around other people. Being alone is the easy part.
Group work is a process of learning to relate, learning to unravel fantasies of having completely unique feelings. Instead of returning us to our own separateness, the group aims to help its participants to see what our experiences share in common. We arrive at and depart from the sessions on our own, but the moments when it feels like the group is working are those where the distance is closed—even if just for a second—and we make actual, meaningful contact with one another. The Distance Cure does not discuss the experience of group therapy in any sustained way, beyond a brief mention of Wilfred Bion’s group experiments with soldiers at a military hospital during the Second World War. Zeavin’s omission of group-analytic psychotherapy is no great misdeed—it is, after all, a minor and slightly outré branch of the talking cures, and one that raises different challenges, provokes different feelings, meets different needs than individual therapies. But it provides a potent reminder of what all therapy can offer: having nowhere to hide, so that we can come to terms with the many ways we resist being vulnerable to one another.
The distanced intimacy of remote therapy during the pandemic has granted too much space for doing just that. It is easy to use the screen as a barrier or a defense, it is easier to let yourself and others off the hook, it is easier to intellectualize about how the pandemic has affected our experience of meeting as a group, and it becomes much harder to work through how we might actually feel about all this, rather than what we might think about it. In person we may well find other ways to hide from ourselves or each other, but when you have a ready scapegoat to hand in the form of Zoom, it seems that we’re likely to blame that—the distance we experience through Zoom quickly becomes an excuse allowing us to wriggle out of any deeper engagement. We moved to remote meetings through necessity, and as interesting as the conversations about Zoom can be, they can also feel as if they are using up time that could be spent on something else. Then again, what happens inside the consultation room—or the Zoom call—reflects what happens outside of it, and if the group has found itself stuck discussing the conditions of our distance, over and over, it’s because it has been equally difficult outside of therapy to find much else to talk about.
During the various lockdowns in the U.K. last year the group felt like an anchoring point in the unstructured, empty time of the long weeks at home. It gave us all an opportunity to work through what we were feeling about the pandemic: the shock and the boredom and the worry of it all, everyone’s various adaptations and maladaptations. There were members saying it felt like nothing had changed, and members who felt like the world was ending. But far more than we discussed the virus, or our feelings about the virus, the group spent its time talking about how we were talking to each other, about phone calls and about Zoom and about what it would be like to meet in person again, whether or not we would even want to meet in person again if and when it became possible. “What do we miss in each other when we meet in this way?” the conductor asked us recently. “What is it that we don’t see here? Apart from each other’s legs.”
My group has, at last, returned to in-person sessions. After months of talking about it, and a couple of postponements due to members coming down with COVID (a handy reminder that the pandemic is not, by any means, over), we met in the flesh last week. It was raining heavily, and as I walked the twenty minutes to the consulting room, getting soaked, I found myself wishing we were still on Zoom. The makeup of the group has changed significantly since March 2020: other than the conductor, only one member remained who I had met before the remote sessions began. Suddenly it became glaringly obvious that, despite spending so much time talking to each other, most of us had never actually made eye contact.
There was a long silence as we all grappled separately with the odd feeling of sitting in a circle looking at each other. I could feel the silence in my body; I was attuned to my breathing and my posture and my heartbeat in a way that I had never felt on Zoom. I was reminded of Quaker meetings, the feeling of connection that emerges through sitting in silence together. The atmosphere felt charged, intense. And then, someone spoke, about the weather, about something annoying that had happened to them that day, and we got on with the same things we usually get on with. But it was different: emotions were evoked that, in the remote session, I would have had to really focus on in order to dredge up. When things got a little boring or tedious, as they sometimes do, instead of drifting off from the conversation, I felt the hard edge of the boredom as a physical discomfort, and I found I could use it: I could talk about it here, when I might have just zoned out and looked out the window at home, knowing I could get away with ignoring it.
Not every in-person meeting will feel like this one long-anticipated session. It will become normal, routine, and like the Zoom sessions themselves, the work will change again in tandem with what changes in the world outside the consulting room. Remote therapy was a bridge, a necessary solution to an unavoidable problem, and I don’t know how I would have coped without it. But once we were back in the same room again, I stopped simply thinking about how I relate to the others, and was forced back into feeling our relating. It was harder, more exhausting, even painful. It was, in its own particular way, thrilling.