Use of the Telephone in Psychotherapy (Book Review)

Author:  Aronson, Joyce
Publisher: Northvale, NJ: Jason Aronson, 2000
Reviewed By: Martin Manosevitz, Fall 2002, pp. 26-28

Joyce Aronson’s edited book: Use of the Telephone in Psychotherapy is a timely publication. It is a collection of 21 chapters divided in to six sections. The chapters were written by a diverse group of psychologists, social workers and psychiatrists, many of whom work within a psychoanalytic model. Four of the chapters had been previously published. Several chapters are filled with rich clinical material. Aronson has made an effort to select papers that are eclectic and far ranging in application of the telephone in psychotherapy-from individual intensive therapy, psychoanalysis, family therapy, couples therapy to therapy with children, adolescents and the medically ill.

I call this volume timely because in the past few years there has been increasing discussion and writing on the use of the telephone in psychotherapy. That is, intervention beyond crisis, suicide, referral and information hotlines. An example of this phenomenon is the Division 39’s symposium on psychoanalysis by telephone presented at the APA Annual Convention in August 2000, (Manosevitz, 2000). This is a topic that heretofore has been all too neglected—given the quite widespread use of the telephone in various forms of psychotherapeutic intervention. There also is an increasing interest and use of other forms of providing psychological services such as audio-video connections and e-mail.

In her Introduction, Aronson notes, “… serious consideration of the therapeutic implications of telephone contact between patients and therapists has lagged behind the actual practice…. it [the telephone] has rarely been addressed as a viable option in traditional psychoanalytic treatment” (2002, p. xxiv). Thus she edited this book because of

The paucity of literature on the subject, the absence of open discussion among colleagues, the lack of information available in graduate and postgraduate training programs led me to bring together the chapters in this book. I hoped that the effort would leave professionals feeling less hazy in their understanding of the practical, theoretical and technical implications of the increasing use of the telephone in psychotherapy. (xxv)

This book, especially sections I and II should be of interest to all psychotherapists. However, it may be of special interest to psychoanalysts who provide intensive treatment experiences and have patients who travel, become ill, have temporary business assignments out of town or are otherwise unable to come to the office for sessions. Using the telephone is a way to continue the analytic process. The chapters in sections I and II provide suggestions on how to offer these services. Because so many therapists who do telephone work report feeling anxious and sometimes guilty about doing psychotherapy over the telephone the examples in this book may help them cope with such feelings.

Several main themes emerge from the Introduction and the nine chapters that comprise section I and II. One theme is the shroud of secrecy around the use of telephone in ongoing psychotherapeutic processes-especially psychoanalytic processes. This is seen in the relatively few papers published or presented on the use of the telephone in psychoanalysis. Yet the use of the telephone in psychoanalysis goes back to at least 1951 when Saul first wrote about using the telephone in his psychoanalytic work. Aronson notes, colleagues “confessed” to her that they had been doing telephone treatment. I found that to be true in my experience. In fact almost every therapist I have asked has “admitted” that they have used the telephone for psychotherapeutic sessions and in some cases for lengthy periods of time. “… I have encountered therapists who, though reluctantly, have acknowledged their own use of telephone treatment for those patients with whom they have felt particularly connected and with whom there was a particular need” (Plummer and Stark, 2000, p. 119). I am reminded of a similar phenomenon of many years ago (circa 1950’s), the time of the “birth” of family therapy. Psychiatrists, social workers and psychologist’s “admitted” that they were seeing the entire family in the same room for sessions! and not using the split model of identified patient being seen by an individual therapist and the parents seeing another therapist. Of course the “unidentified” patients i.e., the siblings were not being seen at all!

In addition to the atmosphere that psychotherapists referred to as a sense of “admitting” that they were doing telephone psychotherapy, as if they were doing something wrong because of unresolved counter transference problems in the analyst, poor technique or worse, there is a theme, in several of the chapters of this volume, which suggests that analysts “waited” for a request for continuation of therapy on the telephone to come from the analysand. Perhaps this is an antidote to the analyst’s guilt or anxiety—the analysand made me do it.

There also is a recurrent theme of disinhibition of affect that sometimes appears when working with an analysand on the telephone. Thus more direct expressions of affect such as anger may be present in telephone work. Another theme indicates more equality in the relationship. The patient starts the session, not the therapist, i.e., the patient rings the telephone for the start of the session— not the analyst opening up the door to the waiting room. There also is the theme that when the patient initiates the shift to telephone work for a temporary period of time, the flexible response on the part of the analyst is paramount to maintaining a therapeutic alliance.

Another component of flexibility discussed in several of the chapters is the necessity of flexibility and collaboration between analyst and analysand on the use of the telephone. It is often embarked on a provisional or experimental. In fact it may be that analysts are more reluctant to embark on such experiments than analysands. Analysts may be more talkative on the telephone. Both parties need time to adjust from the office sessions to telephone sessions. However, that process of adjustment requires analysis. Clearly the use of the telephone is an alternative to termination or transfer. Sometimes, it may be the best alternative. At other times it might become a treatment of choice as pointed out by various authors in their chapters in Section II of the book.

While it seems that no one is, at this time, recommending that a therapeutic process start out on the telephone, there does seem to be more flexibility in shifting to a telephone modality. This may be for a brief period time to weather a particular therapeutic storm or a period of time when the analysand is living in another city. However in other situations it may be wise to continue and finish an analysis instead of transferring to another analyst when there is a permanent geographical relocation of the patient or analyst.

Another theme that emerges from several papers involves the benefits of telephone therapy in many cases--surely not in all. Lindon as early as 1984 (reprinted in this volume) noted “ I have been surprised at how easily the psychoanalytic work can be continued using the telephone if the analyst continues the mode of analytic listening.” (p.6).
A chapter by Zalusky is essentially her earlier report of completing an analysis over the telephone after the analysand moved away. It is a fine contemporary paper detailing important issues in doing and completing psychoanalysis over the telephone. Warren has an interesting chapter on the use of the telephone when the therapist moves. She demonstrates how her use of telephone consultations helped her patients make the transitions to their new therapists and also how that was of assistance to her as she went through her emotional process of leaving one practice location and arriving at a new one.

A number of writers, including Spiro and Devenis in their chapter, noted that the manner in which the telephone is used in an ongoing analysis is what is important. Like any aspect of a treatment, when a parameter is introduced, the analysis of that parameter is what is crucial so that the treatment can advance. Spiro and Devenis make the “bold” statement…” that in very specific ways the use of the telephone actually enhances the psychotherapeutic process and is therefore at least as good as, and oftentimes superior to, face-to-face work.” (p. 69). They then go on to share their considerable clinical experience in support of this contention.

A number of authors discuss the advantages and disadvantages in the use of the telephone and the important question of patient selection. These discussions should be of help to analysts contemplating continuing an analysis via telephone for a period of time while office visits are impossible or completing an analysis over the telephone when circumstances prevent sessions in the office.

Strean’s chapter is an excellent primer and reminder concerning the first telephone contact between patient and psychotherapist. He discusses issues that are present in the initial call and gives excellent suggestions for dealing with resistances and anxieties that are present.

The third section of the book is on the use of the telephone with parents, children and adolescents. Reading these chapters will reward psychoanalysts who work with children and adolescents. Children and adolescents use the telephone in many diverse ways. The analyst’s attunement to connecting via telephone in adolescent therapy is extremely important. In these chapters some useful clinical material is presented and discussed.

The fourth section of the book is devoted to presentations that exemplify how the telephone can be used in treatment modalities other than individual therapy. Thus there are chapters on couple, family and group therapy. The fifth section contains chapters on the use of the telephone with different diagnostic populations such as substance abuse and anorexia. The chapter by Brisch on attachment disorders is especially informative. He uses attachment theory to guide interventions and use of the telephone. The chapter by Mermelstein on the use of the telephone when patients have medical problems and are unable to come to the office is an excellent piece. The importance of maintaining therapeutic contact during illnesses and the usefulness of telephone therapy when one is medically incapacitated as a way to help patients deal with the emotional aspects of their illness and /or treatments is appropriately emphasized.

The last section of the book contains an extremely important chapter for the development of our field. In it Schaffer presents a thoughtful discussion and raises important questions on the legal and ethical issues that arise when providing psychotherapy over the telephone. There are issues that the mental health professions will need to resolve rather quickly. He lists the following as the main issues: licensure when providing psychotherapy services across state and national boundaries, ethical issues, confidentiality and privacy, professional liability insurance, third party reimbursement and issues regarding regulations and litigation when psychotherapy crosses jurisdictional lines. The current status of these important issues are reviewed and summarized.

Schaffer’s review clearly indicates that many of these issues are in need of considerable further discussion and eventual resolution—resolution in which practitioners must be deeply involved. It is much preferred that we actively be involved in deciding these issues—much better than having them imposed on us by non-practitioners or by case law. It is important than many of the issues be resolved so that psychotherapists and patients can be clear about them and thereby avoid misunderstandings (or worse) when psychotherapy is provided over the telephone.

Schaffer provides a list of risk management procedures one may use to limit liability when providing psychotherapy via the telephone. His list contains excellent guidelines for the psychotherapist.

In closing I wish to refer back to Aronson’s introduction and comment about the lack of information in training programs on providing telephone psychotherapy. This volume contains many excellent chapters that teachers and supervisors can assign for reading by students and supervisees to assist them in thinking through the merits of telephone psychotherapy as they consider that modality in specific cases. Thus Aronson’s book is of great service to those who are involved in training and to their students.

Lastly, it is my hope that this book will stimulate more writing and research on these topics so that future generations of psychotherapists, and especially psychoanalysts can approach telephone therapy (and perhaps other electronic modalities) with a greater sense of comfort and professional grounding.

References

Manosevitz, M. (2000, August). Telephone psychoanalysis: Talking about
bodily states in the absence of visual cues. Paper presented at Symposium: Talking Cure in the 21st Century—Telephone Psychoanalysis. American Psychological Association 108th Annual Convention, Washington, D.C.

Reviewer Note

Martin Manosevitz is in private practice in Aspen Colorado. He was Professor of Psychology at the University of Texas at Austin. He was a founding member of the Austin Society for Psychoanalytic Psychology. He is the Division’s Observer to the Committee for the Advancement of Professional Psychology and is Treasurer-elect of the Division.

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