The analyst as user illusion: therapy in the time of COVID-19.

In his essay The Spiritual Problem of Modern Man, Jung states that 'The spiritual problem of modern man is one of those questions which are so much part of the age we live in that we cannot see them in proper perspective. Modern man is an entirely new phenomenon; a modern problem is one which has just arisen and whose answer still lies in the future' (Jung 1928, para. 148). During the pandemic, analytic treatment largely moved to online platforms. I propose an examination of the implications of video therapy for our experience and understanding of the analytic frame and container. Through the introduction of Marina Abramović's performance piece entitled The Artist is Present, which took place at MoMA, New York, in 2010, I explore some reverberations of technologically-mediated sessions. By putting Abramović's piece in context with some of my experiences, I draw conclusions regarding a technologically-mediated therapeutic paradigm. Supported by writings from authors André Sassenfeld, Tor Nørretranders and Iain McGilchrist, I introduce the concept of 'exformation' and investigate different neuroscientific presets of human perception and communication. I will ask how they might affect online therapeutic work and our experience of an embodied versus a virtual co-presence.

The ability to switch to screens was undeniably a vital tool in facing the restrictions imposed by the pandemic, turbo‐charging the shift in the analytic paradigm that was well underway before COVID‐19. Therapists and patients widely embraced the new frame for therapeutic work. Many predict that they will continue meeting online, even when in‐person sessions will be safe again. Therapists and clients have virtually entered each other’s homes. Analysts have met their patients’ pets, taken in their daily surroundings. In a Washington Post article, psychotherapist Lori Gottlieb (2020) summed up her experience: ‘Online therapy, it turns out, provides a sense of intimacy I hadn’t anticipated’. Gottlieb was a pandemic convert to telehealth, having long resisted the sacrifice of co‐presence for the convenience of online work. She quotes a colleague who describes screen to screen therapy as ‘doing therapy with a condom on’. In my own practice I noticed that while initially everybody accepted the switch as an adaptation to an unfolding crisis, resistances soon emerged. The possibility of being hacked, of surreptitious listening in by family members or the government triggered feelings of paranoia, control issues and persecutory anxieties. While those instances were illuminating moments for the treatment, they introduced an additional layer of suffering into what is already a challenging process, the ‘opus contra naturam’.

The pressure to comply with the new modalities is tremendous. Many studies attest to the viability of an online therapeutic alliance. One, published in Clinical Psychology & Psychotherapy by Simpson et al. (2020), affirms that ‘in light of the strong evidence base for video therapy … psychotherapists do not need to be apologetic in transitioning their clients from in person to video therapy sessions but rather view this as an opportunity to provide a seamless mental health care’ (p. 412). The authors refute resistance with a stern reminder that psychotherapists need to ‘meet the challenge of using these instruments to advance our practice’. Failure to ‘grasp the challenge of shaping the future of psychotherapy in the context of a technology‐driven world’, will result in ceding the terrain to online ‘nonprofessionals’ and may even ‘constitute neglect of our responsibilities as practitioners to meet the requirements for best practice’ (p. 417).

What would Jung have made of the ‘seamless’ experience of screen sessions? He hints at the complexity of the question when stating ‘The spiritual problem of modern man is one of those questions which are so much part of the age we live in that we cannot see them in proper perspective. Modern man is an entirely new phenomenon; a modern problem is one which has just arisen and whose answer still lies in the future’ (Jung 1928, para. 148)

Undoubtedly, the most basic aspect of the analytic experience lost to the pandemic is embodied co‐presence. In The Artist is Present, performance artist Marina Abramović (2010) sat eye‐to‐eye with museumgoers, engaging aspects of the analytic process, such as mirroring and evenly suspended attention. What made these encounters so powerful was co‐presence in the absence of spoken language. The mere act of seeing and being seen resulted in an upwelling of emotions. Abramović’s piece exemplified Jung’s contention regarding the mutual influence of analyst and analysand. ‘For two personalities to meet is like mixing two different chemical substances: if there is any combination at all, both are transformed’ (Jung 1929, para. 163).

In ‘The body in Jung’s work: basic elements to lay the foundation for a theory of technique’, André Sassenfeld (2008) explores questions around Jungian analysis and the body from a relational perspective. He posits, ‘Based on the findings of infant research and attachment theory, Beebe and Lachmann (2002), Orbach (2004), and Sassenfeld (2007) consider what they call the “relational body” to be a nonverbal vehicle of communication and interaction’ (p. 2).

Jung was interested in the mind‐body connection from the get‐go, as demonstrated by the still relevant word‐association test. Sassenfeld (2008) elaborates on the various ways that the complexes identified by the test express themselves somatically and how ‘this ascertainment is of great utility’ (p. 3) for the clinician. He quotes Deldon A. McNeely (1987) stating that, ‘it makes possible the recognition of the presence of a complex based on “postural characteristics of the body as well as chronic emotional reactions, somatic symptoms … and other physiological manifestations of tension”’ (p. 3).

Sassenfeld (2008) differentiates between implicit and explicit knowing. He describes implicit knowing as a form of comprehension that contains the individual’s history but can be updated through new experiences. He distinguishes it from explicit knowing, which is language‐based and fairly accessible by consciousness. Sassenfeld references research which demonstrates that in‐session micro‐changes can be related to small modifications of the nonverbal interaction patterns of patient and therapist and concludes that a crucial part of therapeutic process is the making conscious of embodied and nonverbal interaction patterns within the analytic container. This includes not only more easily discernible enactments, but also subtler patterns of visual contact, gestural dialogue, and bodily posture. How is my patient sitting in the waiting room? How do they enter the office? How do I feel in my body as I greet them? Do we make eye contact? How are they settling into their chair, organizing their stuff? Without exchanging a word, through a sequence of embodied action, an inner state can reveal itself, which can then be explored. This is the session as performance piece. What happens to that in a session that begins and ends with the click of a mouse?

Findings from a recent study at Tampere University in Finland imply that physical co‐presence is not necessary to illicit the autonomic arousal response to eye contact (Hietanen, Peltola & Hietanen 2020 ). However, present day applications do not allow for direct mutual gaze or eye contact because of camera position. In an article for the Conversation, Norm Friesen (2020) quotes philosopher Beata Stawarska stating, ‘In eye contact you not only observe the eyes of another person’, but this person is also, ‘attending to your attention while you are attending to hers’. This, as observed by philosopher Maurice Merleau‐Ponty, creates multiple levels of awareness. ‘I look at him. He sees that I look at him. I see that he sees it. He sees that I see that he sees it’. As a result, ‘there are no longer two consciousnesses, but two mutually enfolding glances’. This mutual enfolding seems entirely palpable in Abramović’s (2010) performance piece. Merleau‐Ponty calls it ‘embodied reversibility’ and at this point in time it cannot be achieved in a telehealth setting. Just think of those moments when the image freezes or gets choppy and the stream of the person’s voice continues to flow uninterrupted or vice versa. The disjointedness of visual and acoustic queues is jarring, disorienting and isolating. In the absence of embodied reciprocity, videoconference participants can feel surveilled, worrying how the ‘unblinking camera eye’ may show them to others.

Gillian Isaacs Russell (2015) in Screen Relations quotes a patient, Tanya, as saying ‘When you share physical space, even if you don’t act it out, there is always the potential to touch, whether that means kicking or kissing’. … ‘When not in a shared space all physical potential is taken away, but the important thing is to have the potential, not necessarily the acting out’ (p. 39).

The electronic device itself invites some reflection. Psychoanalyst Todd Essig (2015) in his Foreword to Isaacs Russell’s (2015) book declares, ‘Both books and screens are wonderful Cartesian devices. They let us know who someone is by sharing their thoughts at a distance. Yet is a Cartesian device enough for treatment?’ (p. xv).

In The User Illusion: Cutting Consciousness Down to Size, Tor Nørretranders (1991/1998) addresses questions related to the ‘bandwidth of consciousness’ and ‘the half second delay’ between electrically discernable brain activity and action, known as the brain’s ‘readiness potential’ (pp. 124, 213). He asks us to consider that every second our senses take in over 11,000,000 bits of information. The most generous estimate is that we can process 40 of them consciously, raising the question of what happens to the rest?

Nørretranders (1991/1998) asserts that ‘Consciousness presents us with sensory data that have already been heavily processed, but it doesn’t tell us that …. A mass of sensory information has been discarded before conscious awareness occurs – and this sensory information is not presented. Yet the experience itself is based on this discarded information’ (p. 288).

Contrary to what we might assume we do not actually experience ‘raw sensory data but a simulation of them. The simulation of our sensory experiences is a hypothesis about reality …. What we experience directly is an illusion …. It is this illusion that is the core of consciousness, the world experienced in a meaningful, interpreted way’ (p. 289).

The user illusion … ‘is the picture the user has of the machine’. An example would be the image of your computer’s desktop with its folders and trashcan. Nørretranders (1991/1998) suggests this ‘is the simplified myth’ we have about our device (p. 291). There is of course no trashcan tucked away in our laptop, just enormous numbers of sequenced 0’s and 1’s. Yet, the metaphor for deleting your files works perfectly, up to the satisfying crumpling sound, when you permanently delete the file. It is almost as good as crumpling up the real paper. Almost. Likewise, talking to your analyst online feels almost as good as talking to them co‐presently.

Todd Essig (2015) points out that, ‘Remote treatment is likely on an accelerating curve leading to emotionally intelligent programs running photo‐realistic avatars totally indistinguishable from what people encounter on their screens’ (p. xvi). A simulation within a simulation, nesting inside yet another simulation, the analyst‐interface, as ‘user illusion’.

How then does effective communication work? Nørretranders (1991/1998) contends that it relies on all the processed and discarded raw data, which does not become conscious but remains implied as context. He calls this ‘explicitly discarded information exformation’ (p. 92).

Nørretranders states:

The idea of transmitting information is to cause a state of mind to arise in the receiver’s head that is related to the state of mind of the sender by way of the exformation referred to in the information transmitted. The idea of sending information is that the mind of the receiver must contain some inner information related to the exformation the sender has in his head. The information [in an analytic context an interpretation, a question] transferred must elicit certain associations in the receiver.

Exformation is the history of the message, information the product of that history. Each is meaningless without the other; information without exformation is vacuous chatter; exformation without information is not exformation but merely discarded information.

Whereas exformation is everything we do not actually say but are holding implicitly when, or before, we say anything at all, information is the measurable, demonstrable utterance we actually come out with.

Michael J. Bennett (2001) elaborates on Nørreatrander’s (1991/1998) concept in The Empathic Healer: an Endangered Species?, suggesting ‘that we, as social beings, have learned nonverbal means of communicating exformation … that we are attuned to send and receive the full array of what we might have communicated while in fact saying less’. This, he posits, has ‘great relevance for psychotherapy in general and empathy in particular …’ and wonders ‘if empathy can be considered the means by which exformation is exchanged’ (p. 139).

Abramović’s (2010) one‐on‐one sittings are devoid of explicit information but awash with implicit exformation. These ‘micro‐sessions’, with their engagement in mutual gaze, are a formidable illustration of what occurs in an embodied, co‐present setting.

Does exformation, then, represent the bottom line, the unconscious‐to‐unconscious connection between analyst and patient from Jung’s (1946) diagram in Psychology of the Transference? And what happens to the transmission of exformation, all that unspoken but implied context, in a virtual setting? Does not video‐conferencing add extra layers of fragmentation, encoding and decoding, on top of its inherent delay and potential for glitches, to an already immensely complex process of data transmission?

Analysts and patients report more difficulty in remembering computer‐mediated sessions. Other concerns pertain to the analytic frame and the device itself. What does it do to the process that I can be ‘in session’ with the click of a mouse, and sign off the same way at the end? Or whenever I feel like it for that matter. What about the embodied transitions in and out of the reflective space of the session? How much do they matter? What about the capacity for reverie, tolerating silence, engaging in ‘evenly suspended/hovering attention?’ Video‐conferencing participants describe feeling intensely focused on the screen, which is anathema to those states. All of these considerations make for a different container than the one we have traditionally held in mind. Yet undeniably something occurs in both situations.

What about the computer itself, which is used for so many other things, from online shopping, work, taking or sending photos, posting or consuming social media, to watching movies or pornography? Multiple windows can be open simultaneously, allowing for monitoring of texts, emails, the stock market, news headlines, all while being in session. What about the pop‐up frame that shows us an image of ourselves ‘in session?’ Russell (2015) relays that, ‘The analyst has no way of knowing what the screen set‐up of the patient is. This can lead to both distraction and deception. One therapist found, through a chance remark, that for the first year of treatment the patient had been looking exclusively at himself, his own video picture blown up on the screen, throughout every session’ (p. 131). What about dropped connections? Russell quotes Winnicott’s comments about ‘continuity of being’ stating, ‘When there is a breakdown in presence, the breakdown in connection for many patients is a literal re‐enactment of previous traumas’ (p. 129).

Following her MoMA project, Abramović (2016) participated in a study on Neural Synchrony, inviting us to look at the brain. After all it is with our brain that we developed the machine we utilize for video‐conferencing and the language we use to communicate. Telehealth puts a huge load on language as the means of exchange of information, cutting out the non‐verbal exformation. Gerald Edelman (1989) in The Remembered Present suggests that ‘consciousness may be seen as the haughty and restless second cousin of morphology … and language its poorly paid secretary’ (p. 273).

In The Master and his Emissary, Iain McGilchrist (2010) delves into a meticulous exploration of our two brain hemispheres. The following quote, attributed to Einstein, from RSA ANIMATE: The Divided Brain seems to presage the entire premise of McGilchrist’s endeavour – ‘The intuitive mind is a sacred gift and the rational mind is a faithful servant. We have created a society that honours the servant but has forgotten the gift’ (McGilchrist 2011). McGilchrist investigates consequential differences of our split brain, how they shape the way we experience and inhabit the world, and how human history and culture have been moulded and dominated by either of the hemispheres. Freud and Jung are credited with understanding how the configuration of our brain shapes our experience. McGilchrist references Jung regarding the ancient origin, history and transmission of our brain structure. And he says that the two hemispheres are distinguished as follows: ‘Experience is forever in motion, ramifying and unpredictable. In order for us to know anything at all, that thing must have enduring properties. If all things flow, and one can never step into the same river twice – Heraclitus’s phrase is a brilliant evocation of the core reality of the right hemisphere’s world’ (p. 30). McGilchrist, echoing Nørretranders (1991/1998), describes the challenge as having to step back:

from the immediacy of experience, stepping outside the flow. Hence the brain has to attend to the world in two completely different ways, and in so doing to bring two different worlds into being. In the one, we experience – the live, complex, embodied, world of individual, unique beings, forever in flux, a net of interdependencies, a world with which we are deeply connected. In the other we ‘experience’ our experience in a special way: a ‘re‐presented’ version of it, containing now static, separable, bounded, but essentially fragmented entities … on which predictions can be based.

In other words, the world of technology and computing. The enormous totality of the implicitly received sensorial input gets filtered, sifted, sorted and categorized, eventually to be represented explicitly with help of language, by the left hemisphere.

Can we broaden our understanding of what constitutes exformation to include the intuition of an interconnected whole that is nonverbal, implicit and contextual and thus the domain of the right hemisphere? The left hemisphere, in contrast does the sorting and categorizing, which eventually gets explicitly expressed in language and concepts as information. Exformation ‐ the preponderance of raw data that does not get expressed verbally ‐ hovers in the background and is transmitted implicitly.

Consequently, McGilchrist (2010) proposes that ‘Only the right hemisphere has the capacity to understand metaphor’ and underscores how ‘metaphoric thinking is fundamental to our understanding of the world, because …. It is what links language to life’ (p. 115). But if we mostly use language to communicate our understanding of the world, we have a conundrum: to allow the non‐verbal right hemisphere to speak we have to use language, the domain of the left hemisphere, whose way of processing experience we are trying to circumvent. The left hemisphere, McGilchrist concludes, ‘is a wonderful servant, but a very poor master’ (p. 437).

McGilchrist (2010) has some important observations to share about the body. He argues that while it might seem as if we are actually overvaluing the body through our obsessive preoccupation with fitness and healthy lifestyles, the opposite might actually be true. He posits ‘The body has become a thing, a thing we possess, a mechanism…. That mechanistic view derives from the 19th century scientific world picture, which has lingered with us longer in biology and the life sciences than in physics. The body has become an object in the world like other objects, as Merleau‐Ponty feared’ (p. 438).

According to McGilchrist (2010), ‘the body performs like a work of art’ in the way Merleau‐Ponty proclaims ‘that we do not see works of art, but see according to them’ … a vital process which renders them ‘transparent’. Thus, ‘we live in the world according to the body, which needs its transparency, too, if it is to allow us to be fully alive’. This constitutes what Merleau‐Ponty called ‘the necessary transparency of the flesh’ (p. 439). McGilchrist juxtaposes transparency of the flesh to opaqueness, suggesting that if flesh is opaque it is literal, explicit and concretized. He uses pornography as an example, reminding us of Gottlieb’s (2020) friend who likens ‘screen relations’ to ‘doing therapy with a condom’. McGilchrist references Alain Corbin’s (1988) assertion that ‘sight, the coolest of the senses’ the one most prone to detachment and the one we rely on heavily in video sessions, ‘has come to dominate all’ concluding, ‘Everything about the body, which in neuropsychological terms is more … mediated by the right hemisphere than the left, makes it a natural enemy of the left hemisphere, the hemisphere of ideal re‐presentation rather than embodied fact’. The left hemisphere heavily favors its own creations and ‘the ultimate rebuff to that is the body’ (p. 440).

Brent Orrell (2020), in a post for the American Enterprise Institute, succinctly summarizes what McGilchrist (2010) elucidates about the way the brain creates our experience of world. The two hemispheres are hopelessly out of balance. The relationally minded, insightful right hemisphere, the one that creates exformation, the so‐called ‘master’, is dominated by the more dogmatic, linear and literal ‘servant’. This imbalance is the result of centuries of evolving strategies of cognition that favoured the left hemisphere, our serial processor over the right one, our parallel processor. The left hemisphere is not devoid of emotion, but, as Orrell notes, it is noteworthy, especially in an increasingly mediated world, that the emotion that ‘lateralizes to the left most strongly is anger’. It seems crucial to remember that when engaging in remote analytic work, we are using a device that is largely the product of the left hemisphere, and when we use language, the ‘poorly paid secretary’ of consciousness, as our main communication tool, we are further empowering the ‘servant’s’ grip on our experiences and narratives.

The mixing of two chemical ingredients, the exchange of exformation, cannot occur remotely. It requires co‐presence of both substances. By upholding and, in time, returning to the analytic model of co‐presence, we are safeguarding the ability to hold in mind and minimize possible interference rather than hanging on to outdated modalities or resisting a ‘seamless’ therapeutic experience. By moving the body out of the literalization and ‘opaqueness’ of the left hemisphere, by engaging and acknowledging both hemispheres, analysts and analysands are working towards ‘micro‐changes’ in a process of ‘mutual enfolding’ and ‘embodied reversibility’. Like Abramović’s (2010) sittings with strangers, we as analysts are engaged in a subversive action, an attempt to restore ‘transparency to the flesh’.