The Coronavirus Epidemic: Transference and Countertransference Considerations With Remote Therapy

Posted on May 6th, 2020 by Dr. Blumenfield

The Coronavirus Epidemic:  Transference and Countertransference Considerations With Remote Therapy

Michael Blumenfield, M.D.

The Coronavirus epidemic has forced psychotherapists to see patients remotely as we are forced to follow social distancing and in many cases remain quarantined.  I and others have made the case that remote sessions via Zoom, Skype, FaceTime, Doxy, and other systems are not only a safer method to follow during this time of the dangerous epidemic, but under certain circumstances may be more effective than the patient and the therapist sitting across from each other wearing protective masks.  Remote therapy also eliminates travel time for the patient, which often is not only a safety factor during these times, but can be quite valuable as well as convenient for the patient.  I have advocated that as long as there is any health consideration, this method should be continued and have also suggested that when the health crisis has completely passed, therapists and patients may favor continuing the utilization of remote sessions.

However, as we consider making remote sessions the norm, we have to examine how changes in the method of therapy will impact our therapeutic techniques.   Particularly for those of us who are psychoanalysts or psychodynamic therapists, we will need to consider how utilizing remote sessions will impact transference and countertransference.  As we know, “transference” is the phenomena where the patient experiences feelings about the therapist, which originate in the patient’s childhood usually from feelings that one had for primary relationship in childhood most often from emotions related to his or her parents.  Often such feelings are initially identified by feelings that the patient had towards other people in the patient’s life, but frequently get more clearly expressed in the therapeutic relationship.  The transference relationship is usually facilitated by the therapist being a more or less “gray screen” meaning that the patient usually knows very little about the therapist’s personal life or actual personality.  There are exceptions in training programs where the therapist may be a teacher or may have a strong presence on social media.

Now with remote therapy, we have to take into account how the characteristics of remote therapy will influence the development of the transference, the distortion of it or the facilitation of it.  If the therapist chooses to hold the remote video session in a setting which reveals their personal life (i.e., showing personal photos in the background), that certainly could distort or at least influence the transference.  Obviously, this would be more likely to happen if children or other family members or even pets entered into the background of the setting.  The fact that many remote setups actually present much more of a close-up of each participant’s face could influence the emotional experience of the participants.  Also, the clothes that the participants are wearing, personal grooming or lack of it, will all influence the emotional experience of the participants.  Obviously, all the factors which delay or distort transference will also impact countertransference.  In situations where psychoanalytic therapy traditionally has the patient lying on a couch so they will not be influenced by the therapist looking at them, it would seem that a procedure would be developed where both participants after greeting each other would turn off their video setting.

I believe the transference and countertransference will definitely be influenced by remote sessions.  I am confident that all aspects of transference and countertransference will ultimately take place but they no doubt will be influenced by the nature and characteristics of remote therapy.  It will be incumbent that we use thoughtful observations how these may be barriers or distortions in transference and countertransference with this new method.

There is another aspect of how we use our new therapeutic experience to give us insight into the struggle of our patients.  During the current and apparently prolonged health crisis, social contact especially between single people has become limited to remote visits and this fact of life in many cases is limiting and distorting the emotional experience of these relationships and becomes part of the struggle of the patient.  It appears to me that the patients are uncertain how to evaluate their emotional attachments when the contacts are mostly or entirely via remote communication.  By examining the nature of transference in remote therapy, we will provide a method to give the patient insight into this new struggle.

I am sure there will be many papers and presentations which will be examining these issues.  At this time, I would welcome and invite any comments which you can write below.

4 Responses to “The Coronavirus Epidemic: Transference and Countertransference Considerations With Remote Therapy”

  1. Helen Wynn says:

    I’m just a patient so maybe my comments dont count. But I felt compelled to say your article scares the stuff out of me. I had three years of telebehavorial health and I was never so happy as when my psychologist and psychiatrist switched departments and I was taken along and could have weekly face to face sessions. I talked to my psychologist today about your article and she did seem to agree with you on the future of psychological counseling via internet. Just please remember there are people like me who would not thrive in that environment. Aloha, Helen Wynn

    • Thank you for your comment. Your point is well taken. Perhaps in the future, more often we will have a combination with some sessions being in person and other times we will meet remotely.

  2. Thanks, Michael, for your interesting article. It brings up subtle but important considerations for today. Regarding transference, I have long felt that the phenomenon is remarkably robust. Transference happens in any intense relationship over time and is strong and persistent, regardless of attempts at anonymity and difficulty due to the intrusion of electronics.

    I do think the first comment from a patient tells a lot. My experience has been quite variable. When I feel I “know” the person well, sessions seem quite normal whether it is by phone or video, and I think patients experience it pretty much the same way. It takes longer and is a bit of a strain to get to know a new person, but with those I know well, I have had very satisfying experiences and worked on transference issues. Examples include video sessions with a patient in Asia and phone sessions with a patient who suffered from dissociative identity disorder, multiple personalities, where changes from one state to another were only detectable by subtle changes in voice. We are all learning in this new normal, and need to listen closely to the patients we work with.

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