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Can You Hear Me Now?

A new history of teletherapy highlights the flexibility of the therapeutic frame

The Distance Cure: A History of Teletherapy by Hannah Zeavin. MIT Press, 328 pages.

If you were one of the millions of Americans who started seeing a therapist for the first time during the pandemic—roughly one in six, according to one study—you likely did so on the internet. It’s perhaps equally likely that you hated it, for the same constellation of reasons you hated attending a work meeting on the internet, or a funeral: it was awkward, it made you feel like a participant in a culture-wide descent into simulation, it made everyone look hungover, it removed you from the language with which to accurately describe your experience, it was weird for people to see your unmade bed, you felt as though you had been downgraded to a lite experience while still paying for the premium version, you feared for the privacy of your data and were sickened by the conceptual turn that transformed sentiment into that data, it felt bougie, it felt like a video game, it felt like a supremely humiliating way to spend the end of a certain period of historical naivety, and the link didn’t work.

At the same time, therapists and mental health providers are also experiencing the kind of strain and trauma they may want to talk to a therapist or mental health provider about. Harried by spikes in demand for treatment since the beginning of the pandemic, practitioners are spread thin and turning to any solution that allows them to treat more people with the same finite resources, even if that includes subjecting themselves to the chumbox of TikTok’s algorithm. These pressures are not necessarily new, or entirely the result of the pandemic; rather, they’re an iterative stage in a long crisis of mental health generated by the simple fact that more people need counseling than are professionally licensed to provide it. This was true long before the first appearance of the novel coronavirus and will likely be a circumstance that outlasts it.

The Distance Cure: A History of Teletherapy, a new book by UC Berkeley lecturer and media researcher Hannah Zeavin, offers a timely reminder of how recursive that crisis of care is by tracing how therapists and patients have turned, more willingly and more often than one might expect, to forms of mediation that take treatment from one-to-one to one-to-many. Throughout history, analysts and therapists have traded their couches for radio transmitters, newspaper columns, toll-free hotlines, and the web in an effort to reach more people, to the extent that it may not even be fair to refer to therapy as mediated only when it is novelized by some form of technology. We might instead think of the medium of therapy as an eternally present third in the triad that makes treatment possible: therapist, patient, and the means by which they speak to each other.

In 1913, Freud delivered a paper in which he lingered on one of the first media that psychoanalysis throws up between analyst and analysand:

An analyst does not dispute that money is to be regarded in the first instance as a medium for self-preservation and for obtaining power; but he maintains that, besides this, powerful sexual factors are involved in the value set upon it. . . . He shows them that he himself has cast off false shame on these topics, by voluntarily telling them the price at which he values his time. . . . (It is a familiar fact that the value of the treatment is not enhanced in the patient’s eyes if a very low fee is asked.)

Not only would the frank discussion of money allow a psychoanalyst to “cast off false shame” and show how analysis helps one master primary taboos, it would also encourage patients to listen to whatever part of their subconscious most directly controlled their pocketbook.

Beneath the theory and professional clannishness, a volatile array of personal attachments lurk.

While there was no shortage of European bourgeois willing to pay for the privilege of having their neuroses flattered, the market was ultimately finite. But fees were as integral a part of Freud’s schema of treatment as free association was and could not be dispensed with—effectively robbing the poor and working class of the opportunity to discover their own psychic wounds.

Trauma, of course, has never been costly to acquire, a fact the twentieth century bore out. In 1918, even Freud himself, standing in the precarious moment at the close of the First World War and in the midst of the Spanish Flu pandemic, invoked a vision of public welfare and charitable mobilization of the psychoanalytic front, since “the poor man [would] have just as much right to assistance for his mind as he now has to the life-saving help offered by surgery.” He also understood that the further psychoanalysis was disseminated, the further from “pure” doctrine it would be forced to stray, conceding that “it is very probable, too, that the large-scale application of our therapy will compel us to alloy the pure gold of analysis freely with the copper of direct suggestion.”

For Zeavin, this is a concession that is characteristic of therapy, in which the rigidity of the therapeutic frame is compromised and adapted almost as soon as it’s insisted upon. Beneath the theory and professional clannishness, a volatile array of personal attachments lurk. Changing a single variable spawns successive unknowns. As Zeavin writes: “If you remove the fee, why does the session have to last fifty minutes? Or for that matter, why does it have to be in an office? Or in person?”

Once the foundations of the therapeutic scene were thrown into question, Zeavin shows just how quickly treatment did flee the office and become entwined with the explosion of information technology during the second half of the twentieth century. In the first year of the Second World War, D.W. Winnicott, by then the most influential psychoanalyst not named Sigmund or Carl, began a series of radio broadcasts aimed at wartime mothers in which he spoke to listeners as though they were in a private session with him, snug and secure in his confidence.

This boldly fictional conceit gave way to further experiments with how flexible the therapeutic frame could become when mixed with broadcast radio and, eventually, the telephone. Zeavin outlines how radio enabled both Frantz Fanon and Félix Guattari to take their interest in group therapy and refine it into mass psychic address in the service of revolution. Fanon, recounting how the revolutionary Voice of Algeria, broadcast from Egypt, served as a connection to the Algerian struggle that went beyond the purely informational, wrote:

Often, only the operator, his ear glued to the apparatus, would have the unanticipated chance to hear the Voice. The other Algerians present in the room received the echo of this voice through the device of the privileged interpreter, who at the end of the broadcast was literally besieged. Precise questions were then posed to this incarnated voice. . . . At the end of the evening, not hearing the Voice, the listener would sometimes leave the needle on a jammed wave-length, or one that simply produced static, and would announce that the voice of the combatants was here.

It wasn’t only the revolutionary vanguard who used these new technologies to bring ideology to the airwaves. Zeavin also recounts how the pastoral origins of suicide hotlines, and the pioneering practice of Protestant ministers training lay volunteers to counsel callers in crisis, has led to an unexpectedly deep and profitable relationship between evangelical Christians and communication technology—the result being such American institutions as the toll-free prayer number and the CCTV sermon.

By the late 1950s and 1960s, the world of communication technology had expanded enough that it comfortably included Shockley’s Silicon Valley and Eisenhower’s DARPA, and teletherapy entered a new phase. For cyberneticists, sociologists, and behaviorists who took the Turing Test for an imminent challenge rather than a horizon, computer technology and therapy were perfectly matched authentication tests. Nothing could be more human than the understanding and treatment of human suffering, and no one was more sensitive to the attention of another human than someone in pain.

That the Turing Test has been repeatedly “passed” by programs of both a therapeutic nature and otherwise does more to show its limits as a tool for measuring intelligence than it does to confirm the technological determinism of the kind peddled by Ray Kurzweil or Elon Musk. If anything, the test reveals more about its human control than its computer subjects. One of the most famous examples of computerized therapy is ELIZA, the language processing program and faux therapist that features as one of Adam Curtis’ trademark “strange things that happened” in his popular 2016 documentary HyperNormalisation. ELIZA was designed to demonstrate the superficiality of man-to-machine communication; the Rogerian platitudes it fed back to users would illuminate how quickly computer programs became stuck in unconvincing loops when faced with a live human subject. But the unexpected outcome was that despite users either knowing ELIZA was a machine before interacting with “her,” or how quickly it became apparent once they were, they still found the program to be a source of comfort. Having easy access to a therapist as blindly receptive and infinitely available as ELIZA made people feel good. Patients were able to extract presence from their encounter with the machine in ways that aren’t necessarily guaranteed with a live counselor. As Zeavin writes:

In the traditional human- to-human interaction, many schools of clinical thought have tried to think about and control how the humanness of the clinician presents; therapists are not supposed to make the therapy about themselves. What better way to control this than to remove the self from the therapist? 

The urge to fully automate the role of the therapist dovetailed nicely with an emerging drive to at least partially automate the patient. Today, Cognitive Behavioral Therapy’s ubiquity makes it difficult to perceive how radically it transformed mental health work when it appeared in the 1960s. CBT eschews the slow, archaeological process of psychoanalysis in favor of a briskly managed consciousness; it focuses on increasing productive thinking and tends to dismiss deep introspection as morbid. CBT’s narrowed targets—the way it isolates negative behaviors or thoughts for removal like disobedient carceral subjects—and its emphasis on self-work have become the native language of self-optimization for everyone from ultramarathoners to the male separatists of MGTOW.

Zeavin explores the way CBT’s triumph was assured in part  by the meeting of managerial attitudes toward the psyche and the excitability of technologists. Both the emerging discipline of data science and CBT were modular, quantifiable, dispassionate. Together they fit hand in glove. Because CBT’s efficacy could be measured and ‘proven’ in terms that classical psychoanalysis couldn’t, Freud’s descendants practically found themselves victims of a coup. Or as analyst Todd Essig has it, not a little ruefully: “the results were in . . . and psychoanalysis—lost. As a result, rather than remaining parallel mid-wives to the birth of a new therapeutic age, psychoanalysis and the emerging culture of simulation and enhancement would become adversaries.”

Rather than worrying that technology compromises therapy, better to look towards new forms of treatment that are more just and more accountable.

Zeavin’s book is an unsparing and unsentimental reminder that the elements of this competition—the victors and losers, the terms and conditions—are not given. Tools, both therapeutic and technological, really only come to life when they’re put to use. “Screens, too, are part of human relations,” she writes. “Anything can and will travel across them: violence and trust; empathy, however slight or temporary; connection and disconnection; presence and absence.” Or as the late Lauren Berlant has it, the “cluster of promises” that form our attachments “could seem embedded in a person, a thing, an institution, a text, a norm, a bunch of cells, smells, a good idea—whatever.”

The therapeutic frame is not threatened by mediation; it’s defined by it. The stickiness of human attachments make them difficult to sterilize, and they survive when the therapeutic dyad mutates into a triad or is rerouted through fibre optic cables. If technology feels deadening, it is in no small part due to our persistent misrecognition of it as a conductor of our politics. As Zeavin argues, “Screens don’t destroy empathy, they host its contemporary loss, which is an effect of despair, loneliness, and alienation.”

All mediated communication, which is to say all communication that occurs between human beings, presents a risk. A species as social and evasive as ours has ample opportunities for misunderstanding. To ascribe our contemporary alienation purely to technological sources would be to mistake symptom for cause—the same kind of myopia that assumes there will be a post-pandemic return to normal once the masks come off and CDC guidelines disappear. To sit in a therapist’s office, to face them directly and experience the pleasures of embodiment in that encounter, may feel like a luxury during the pandemic, but it was already a luxury: expensive, criminally inaccessible, undergirded by various prejudices. Rather than worrying that technology compromises therapy, better to look towards new forms of treatment that are more just and more accountable no matter the format in which they occur. After all, it’s our hour—we can spend it how we like.