Tag Archives: telemedicine

What is always there


But seriously, the “project” that was once psychoanalysis, or now psychotherapy or whatever, has been disrupted by Covid-19. Telemedicine, Telehealth, Telepresence, is here to stay, according to some. This is a watershed moment, a bump or a shove into the next paradigm. No going back? Well, I won’t be the only one kicking and not quite screaming, but rather only moaning and possibly sulking. I’ve lost one or two from the caseload: people who perhaps think the virus scare is not what it’s negatively cracked up to be. Or—here’s a thought—maybe they think I’m not all I am positively cracked up to be, and therefore the crisis that’s upon us is a pretext for a separation. Neurosis aside, this situation is not what I trained for. Something’s missing, and something else has been mobilized in response. Temporally appropriate feedback. That’s a term I heard yesterday, used to explain why the phone, the latest video technology, the e-mail, and even the text message might be used for a psychotherapeutic exchange and why the fax machine never was. It wasn’t quick enough, basically. That’s what temporally appropriate feedback means, by the way. Yes, I know. Talk about unnecessary verbiage, someone’s dissertation nomenclature. Anyway, whatever’s happened overnight, it seems tailor-made for opportunists, entrepreneurs; futurist thinkers with a survivalist edge and a nose for the front of a line. I’ve thought about my peers, even some of my colleagues in all of this. Some of them belong in the jungle, I think, pulling at the bamboo, or squeezed into a tight gap beneath a fallen hut or an all-terrain jeep. They have grease on their hands, an ample toilet paper stash, and numbers dancing across their mirrored pupils, for they have versatile, fix-it aptitudes, which means they navigate well all the toys that mediate contact with the material world and which are derivatives of the childhood games they played better than anyone else.

What is always there is never noticed until it is missing, said Jose Bleger. That’s another of those psychoanalytic aphorisms that are meant to stir thought if not practical solutions. What is it that was always there? I have wondered aimlessly instead of, say, moving to use Venmo, or signing up for What’s App, or whatever, as if those were the clues. I don’t skip along a trail of newfangled ideas the way that others who…don’t use words like newfangled and therefore don’t have issues with planned obsolescence, come to think of it. I thought I had an idea, dull as it may seem, of what was and is always there: the analytic frame, manifest as the office space, with a door leading to a waiting area wherein a would-be patient sits and waits for me to open my door and beckon them towards me. It sounds more authoritarian than it is. And it seemed like it still had a few years left in it, too, as paradigmatic frameworks go. Now it isn’t there. Or, it is there but it seems like an abandoned warehouse with a faintly stale air about it. Recently, I’ve not been getting my money’s worth out of my office. It collects mail, a bit more dust than usual. I can go there once a week and make a phone call from it if I like, but it’s not the same. The nice view from the window’s not the same. There’s no collegial hum across the walls that connect to other suites. There’s nothing charming anymore about the rickety elevator that takes me to my floor, or pleasing about the sudden abundance of parking spaces in the adjoining lot. And after the first week of lockdown—not even the consolation of a few toilet rolls to steal from the bathrooms. What was always there? I haven’t figured that out yet, but like a good would-be analyst, I am thinking, still wondering.

Meanwhile, I am thinking of bigger things, philosophical, mindful ideas. Phenomenology, I think. I’m reminiscing, at least, if not deepening. Back in 2001, I thought 9-11 was a fine how-do-you-do to the 21st century. Now I think that episode less an introduction to doomsday than the residue of the last century, with all of its terrorizing, authoritarian ghosts. Not that we don’t have plenty of nutjobs these days, but you don’t beat the 20th century for tyrants and martial horror: two world wars, a couple of nuclear explosions (not counting the tests in the Pacific and the deserts of the American Southwest); Hitler, Stalin, a few other genocides, assassinations all over the place, at least one war that America lost. Seriously, a total s—tshow. But 9-ll, which made household names of Al Queda and a guy named Bin Laden, seems today like a distant memory of airport inconvenience and yesteryear jingoism: a tough deal for anyone sniffing at a military life, but for the rest of us, not the economic and civil collapse that stares at us now. Images of twin towers burning didn’t make the cut of my recent Dr. Strangelove video, with its “We’ll Meet Again” montage of zeitgeist existential threats, 2020-style. Not topical. Scenes of floods, wildfires, stranded polar bears and penguins on thinning ice were the visual accompaniment, not the cold war terror of mushroom clouds or the once Arab stereotype of airplane hijackings. Covid-19 snuck into the slide show with the odd picture of a solitary figure wearing a hospital mask amid empty landscapes, signifying for me, anyway, the ubiquity of the virus’ impact: the live presentation I was meant to give on Strangelove was canceled, after all.

The ‘live’ has always been there. Nature has always been there, and the notion that it won’t be has long felt like an abstraction, despite the slide show of evidence to the contrary. It’s trite to point out that nature is unforgiving, getting its revenge upon us now or else teaching us a lesson, perhaps in the nick of time, depending on what climate change scientists actually think and wonder. It’s further trite to distill the Bleger reverie and consider that what is always there is a warning to not ignore the signs of danger; to notice the impact of phenomena upon others, environments, even things. Indeed, it stirs shame to consider that Covid-19 has aroused more fear, more loss, or more determination than any other modern calamity simply because, unlike any other world event one might remember, this has truly impacted everyone to one degree or another. I conjure the grim-faced, somewhat unsympathetic gaze of those who have known and felt war, environmental catastrophe, unspeakable man-made atrocities or the constant slaps of racism and other oppressions. They may be quietly saying, Oh, so we’re all in this together now, are we? Maybe some of them got a head start. They’re like California, or North Korea or Singapore, or whomever else might have done this thing right. They were and are good with the things, and technology, that which mediates and distances us from nature, enables, intrudes, obstructs, complicates, and yet may save us. It helps…sort of.




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I’m thinking of something


The analytic situation may be studied from the point of view of the methodology it stands for: a framework comprised of technique, context, and the variables of temporal and material reality imposed upon a subject, and therefore the subjective experience. The current analytic situation, rendered “Telepresent” by the outbreak of Covid-19 and the resultant lockdown of motility, brings a range of affordances which disturb the project that is analysis, yielding a new situation, shorn of its familiar parameters of sight and sound, and creating others due to the illusions of both distance and proximity. Nearly forty years ago, during a meeting of the British psychoanalytic society congress, what some dismiss as an apocryphal instance occurred: Society member W.O. Wodcot emerged from his seat to alert his quarrelsome colleagues, “excuse me gentleman, we’ve just invaded the Falklands”. That few in the room had ever heard of the obscure archipelago southeast of Argentina was aptly reflective of a psychic and material reality, the not-happening-here phenomena, as Abstemios (1969) refers to it. Such experiences are echoed in our transitional analytic situation wherein features of telepresence enable a secondary, man-made wall of resistances, most of which privilege an absence that is circumambient to the present experience. “I could be swearing,” exclaims a consultant psychiatrist, referring to the possibility of muting herself within the telepresent framework. “I could be lip-reading” I counter from the viewpoint of resilient, human adaptability. Or, I imagine an aliveness-draining parallel to another famous exchange, this between two notable figures of political history. Lady Astor: “Winston, if I were your wife, I’d unfriend you on Facebook”. Churchill: “Madam, if you were my wife I’d unfriend myself”. This dystopic vision draws our attention to a fresh project: how to restore the “kicking and kissing” problem of psychoanalysis; that lurking danger that lies beneath the veneer of civilized meeting that spares our profession from an imputing of utter hypocrisy.

Building upon Freud (1912), the conditions of a framework that include an analyst’s “evenly hovering attention”, Ariel (1992) offers the permutation, “evenly hovering presence” to signal the totality of the analyst’s being in the analytic situation, both with material and dynamic implications. “What’s the ladder for?” asked a patient when encountering an early experiment in this manner of working. The querulous anxiety in this patient was partly assuaged, according to Ariel, by the observation that note-taking was obviated by the analyst position, due to the risk of falling. This finding highlights the dichotomy of absence and presence that seems intrinsic to theories of change, or as Abstemios (1971) observes in his follow-up work: “Yes, that happens, but then so does something else”. The vicissitudes of affect, and of subjective experience in its entirety, is thus impacted by the variables of an analytic situation which, despite the contrivances of technique, process, and setting, are subject to collective contingency. So convinced was Ariel by the impact of the analyst upon the patient within the analytic frame that her homonymic nom d’une analyse was itself subject to mutation at different stages of her career. It is understood that while she never entirely renounced the validity of her “ladder” technique during her middle period, subsequent incarnations of her treatment method have introduced Le Terre analyse to indicate the grounded position of the analyst in the presence of the subject. This quiet failing notwithstanding, the absence of an alternative frame of being, as Obstinach (1975) has described, has hitherto placed a stifling burden upon the evolution of modern psychoanalysis.

The way I have stated this problem suggests the institutionalization of our project, and yet that project continues with the paradoxes of equidistance and absence unabated. The possibilities of thought, untouched by orthodox opinion, and tangential to zeitgeist, or else subsumed within a cornucopia of literature, are obscured over temporal and subjective reality. The inchoate emergence of dissident voices upon the analytic situation signal new affordances in our extant frameworks while echoing the creative opinion of silenced innovators. “That silence is selective”, wrote Quixote (1984), with double-meaning, referring to a patient with selective mutism, but also to a generalized observation that experiences in the patient third, in which an othered space disallows the pressure of the concrete interpretation, is transformed into a collective happening, observable yet indeterminate, and thus subject to disappearance. Falsthink (1987), whose neuroscientific research into the continuity of genomes has been discredited, views this same transformation in the context of a happening now versus post-phenomenon experience wherein subjective experiences of crisis and grief intersect, and then split-off. The dividend of his observation is today present, telekinetically or not, for our close reading and inspection: that what continues is the function of the mind despite the impinging of the environmental third, the vicissitudes of engagement and dissociation. Indeed, this happening accentuates the connection that we and our patients seek. It is our answer, to be alone in the presence of the absence.




Abstemios, J. (1969) The diary of Fogo Von Slack: a dissertation upon smells. Flack lit press, Fargo, ND.

Abstemios, J. (1971) The mother of Moby Dick and the death of whaling. Carnic books, Muncie, Indiana.

Ariel, F. (1992) “Assault upon the frame: the evenly hovered presence”. Eurasian regional journal of free associative discourse. Vol 12: pp.73-73(about two-thirds of a page)

Falsthink, J. (1987). Forget about the genome thing, how about this? Carnic books, Muncie, Indiana.

Freud, S. (1912) “Recommendations to Physicians Practicing Psychoanalysis”, The Standard Edition of the Complete Works of Sigmund Freud, vol 12: 97-108.

Obstinach, O. (1975) “In response to the suppression of Ariel’s ladder technique: a step down” International Journal of Psychoanalytic Controversies not otherwise published. Vol 1, p. 3.

Quixote, Q. (1984) Selective Mutism: the patient who would not be heard…sometimes. Carnic books, Muncie, Indiana.



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