The Interpretation of Screens

The distance cure: a history of teletherapy by hannah zeavin. cambridge, ma: mit press. 328 pages. $35.

The cover of The distance cure: a history of teletherapy

IN STAR TREK: THE NEXT GENERATION, THE ANDROID DATA starts to dream, having accidentally discovered an unconscious he didn’t know he had. Soon, because his dreams are troubled, he enters psychoanalysis. Appropriately enough, he turns to another artificial intelligence for help, the computer of the starship Enterprise, which creates a holographic representation of Sigmund Freud. Later, Data dreams that he is on the Enterprise, standing with two of his companions. A phone rings. But where is it? Data’s friends open a hatch in his abdomen. An early-twentieth-century phone stands there, waiting for someone to answer; when picked up, the phone transports Data and his friends to Freud’s office.

It’s quite an image. The mechanical man discovers new depths inside himself, but he also discovers a telephone—for him, a centuries-old technology, only a little older than psychoanalysis itself. I thought of this image constantly, meditating on its bluntly literal rendering of the idea of a “call” to self-understanding, as I read Hannah Zeavin’s book The Distance Cure. Zeavin, a scholar in the field of media studies, argues that distance, mediated by technology, has always been part of mental-health care, though we usually leave it out of our histories. We ignore teletherapy at our analytic peril, Zeavin argues, because all therapy has involved technological affordances of some kind. Zeavin’s book begins with Freud and then moves on to survey different forms of therapy conducted from a distance: letter-writing, radio call-in shows, advice columns, therapist-simulating computer programs, and “concierge” smartphone apps that connect people with therapists, for a price.

Psychoanalysis might be the science of the soul, but it has never been the science of the disembodied soul. Freud was a medical researcher and clinician, and arrived at his method by attending to the bodies in the consulting room. He knew that voice and hearing were bodily affordances, and that technological aids and prostheses were part of daily life, not to be sneered at. In his 1913 essay “On Beginning the Treatment,” Freud describes how he arrived at his most important technological signature, the couch. Tired of his patients staring at him all day, he decided to have them recline, facing away from him. But he also noted that the arrangement in which a patient lies on a couch while the analyst sits behind them, out of sight, “has a historical basis; it is the remnant of the hypnotic method out of which psycho-analysis was evolved.” Freud went on: “I insist on this procedure . . . to isolate the transference and to allow it to come forward in due course sharply defined as a resistance.” In other words, the “choreography” of analysis influences the patient in a subtle fashion, bringing about the isolation of transference Freud described. But the couch helps the analyst too, supporting Freud’s effort to develop what he called “gleichschwebende Aufmerksamkeit,” or “evenly suspended attention.”

As Zeavin points out, Freud later used the model of the telephone to describe his ideal form of attention: the analyst, he wrote, “must adjust himself to the patient as a telephone receiver is adjusted to the transmitting microphone.” The analogy continued, as Freud compared the analyst’s process of reconstructing the patient’s unconscious to the way a receiver “converts back into sound waves the electric oscillations in the telephone line which were set up by sound waves.” Freud spent much of his career writing about the distance between patient and analyst, and in the phone’s inner workings he found a way to describe his own inner workings, the wiring and attunement of ear and mind.

Star Trek: The Next Generation, season 7, episode 6, 1993. Data (Brent Spiner).
Star Trek: The Next Generation, season 7, episode 6, 1993. Data (Brent Spiner).

But for the most part, Freud wrote letters. Zeavin argues that the first distance therapy was, in fact, Freud’s own, conducted through the mail. The usual way of understanding Freud’s self-analysis is that he performed it alone and reported on it in letters he wrote to his friend and colleague Wilhelm Fliess. Zeavin, however, sees Fliess as Freud’s object of transference and argues that Freud’s was a normal analysis, albeit one conducted by mail. It’s an intriguing revision, the truth of which would require more close reading of the surviving portion of the Freud-Fliess correspondence to ascertain. Zeavin leans heavily on this interpretation, because she wants us to understand that Freud needed distance even within his own analysis, and found that distance in the technology of letters. Even without such a reading, Freud’s correspondence with Fliess suggests that “teletherapy” has always been a kind of potential within psychoanalysis itself, and modern communication technologies have simply allowed that potential to develop.

But psychoanalysis is just one part of the story. No straight line runs from Freud’s telephone analogy to, say, crisis hotlines for the suicidal; psychoanalysis and crisis care are different genres, though you can do them both over the phone. As The Distance Cure’s tour proceeds—covering the psychoanalyst D. W. Winnicott’s radio addresses, the origins of suicide-prevention lines, Charles Slack’s early experiments with tape-recorder-assisted soliloquy—we contemplate many different versions of mental-health care. By the end of the twentieth century, cognitive behavioral therapy had replaced psychoanalysis as a model for mental-health care, and CBT has its own elective affinities with technology, in part because CBT is often short-term by psychoanalytic standards. The Distance Cure gradually moves into the contemporary world, where personal computing is common, and mental-health care is becoming less stigmatized—but where the effort and ambition of psychoanalytic treatment is mostly forgotten. Contemporary teletherapy unfolds in a world where smartphones are as ubiquitous as letters were in Freud’s Vienna. And critically, most forms of teletherapy are lower-cost than in-person therapy, which tends to be “excruciatingly expensive for almost all people,” as Zeavin puts it.

Zeavin avoids asking whether teletherapy can be “as good as” in-person therapy. She is wise to do so; it’s a question you can’t answer without defining mental health itself. But The Distance Cure seems to circle around another, deeper question that Zeavin never quite asks: What is the relationship between presence and healing? Anyone who argues that teletherapy is inherently flawed will probably assert an essential relation between physical proximity and therapeutic effect. If you believe “no office visit, no healing,” then Zeavin’s book will read as an account of a long decline for mental-health care, all the way down to twenty-first-century nightmares in which therapists and patients send each other digital representations of thoughts and feelings via portals created by wealth-seeking entrepreneurs. Indeed, at several points in her book, Zeavin notes that technologically assisted therapy has sometimes seemed to promise the wholesale replacement of expert human therapists with automatic surrogates or gigging humans paid a pittance. As I read, I was distracted by the question of whether or not contemporary teletherapy has become the captive of tech-sector fantasies of scale. I worried about what forms of human attention and care will get sacrificed so that some people can get rich. A world of technologically mediated care networks can be as scary as a world of technologically mediated social networks.

The Distance Cure concludes with a short and powerful portrait of teletherapy during the COVID-19 pandemic, an era whose defining features are distance and a need for cures, not only a vaccine for the virus but also a remedy for the pain of isolation. Early in 2020, teleconferencing became invaluable and omnipresent—the same applications used for work and play and therapy. Shortly after the pandemic began, my own psychoanalyst closed his physical office altogether. Now I recline, pick up the phone, and summon myself to a red couch that no longer lies under a window in Berkeley. I began my treatment on that couch nearly twenty years ago, and I can still remember how novel it was to lie down like that, to drop the customary postures of productive adult life. Freud said only a little regarding its necessity, but I still think that the couch is an admirable framing device, part of what makes psychoanalysis unlike anything else. My own resistance, I joke to myself, found its match in the resistance of that rather firm couch. And yet the phone is an admirable framing device too, isolating the relationship between analyst and patient to a narrow channel, all attention hanging on the voice. Data’s abdomen swings opens like an antique telephone cabinet, and we get symbolism that is no less true for being so obvious: self-knowledge always requires some form of mediation or dialogue, even within the self, and our modern age has given us many mediating tools.

Benjamin Aldes Wurgaft is a writer and historian. His books include Meat Planet: Artificial Flesh and the Future of Food (University of California Press, 2019) and Thinking in Public: Strauss, Levinas, Arendt (University of Pennsylvania Press, 2016).