Transference in Teletherapy: A Case Discussion

With the rapid and widespread shift to teletherapy services in response to the COVID-19 pandemic, teletherapy is a topic of considerable interest to psychiatric providers (1). There is an array of evidence supporting the use of teletherapy, including efficacy for multiple modalities of teletherapy, noninferiority compared with in-person therapy, and patient satisfaction with teletherapy (2). There is also a potential for increased access to therapy services with teletherapy as an option, particularly for group teletherapy (3). However, there is also concern about how this change might affect the therapeutic process. Given the inevitable differences between teletherapy and traditional in-person therapy, it is important to consider how these changes might affect the therapeutic relationship and how they can be best utilized to help patients.

Teletherapy requires a move away from the traditional therapy room, which has historically been viewed as a “symbolic container for the patient’s inner world” (4). Given this significant shift, psychiatrists have expressed concern that their teletherapy sessions with patients lack a holding or containing “frame” that provides a “secure base” for patients to explore their problems (5). As asserted by the psychoanalyst Gillian Isaacs Russell, “the patient is healed through finding in the analytic setting that which should have been available earlier in life: the facilitating environment which holds and contains” (6). One wonders how the lack of a physical room affects the therapeutic relationship and how the psychotherapist can provide the basic conditions for making the environment conducive to therapeutic interactions.

Psychotherapeutic encounters involve transference, which is defined as “the patient’s total experience of the therapist, filtered through the prism of the patient’s history, experience of others, and current state of mind” (7). Whether in-person or virtual, encounters in psychotherapy inevitably involve “irreal” factors, such as symbolism and fantasy (8). The virtual nature of teletherapy offers “an additional dimension of irreality to the symbolic and imagined transference relationship” and can affect interpersonal dynamics between psychotherapist and patient (8). However, this change need not be seen as a hindrance to therapy. Instead, transference in teletherapy can be viewed as a meaningful facet of treatment to understand (8, 9). Additionally, teletherapy may lead to a “safety of distance,” allowing access to fantasies and topics that may not arise during in-person therapy (6).

To help illustrate these concepts, we present a case in which differences in therapeutic settings contributed to new transference reactions among patients participating in group psychotherapy.

Case Presentation

During the COVID-19 pandemic, an in-person resident-led psychodynamic process group was required to convert to an online video-conferencing platform amid social distancing restrictions. This group consisted of patients ranging in age from the mid-twenties to late sixties who were dealing with common issues, such as depression, anxiety, and substance abuse. Group members had been in the group for durations ranging from months to years. Sessions were held weekly with an open-discussion format and had traditionally been in-person, with patients and leaders seated together in a circle. Over a span of approximately 9 months, the two resident psychotherapist coleaders and seven patients logged in for weekly group psychotherapy from their homes. Frequently, one psychotherapist, referred to here as psychotherapist 1, was viewed within his video frame as sitting in front of a blank white wall. In comparison, the other psychotherapist, referred to here as psychotherapist 2, was generally seen in a room that had art on the walls, plants in the background, and the occasional pet passing by in the distance. Over time, it became clear that the patients had developed different reactions to the two coleaders, and these reactions were influenced by their differing virtual environments.

For example, group members pointed out that psychotherapist 1 had positioned himself in front of a white wall each week and claimed that this coleader did not “let them in.” A few of the group members reported that by setting up the environment in this way, the psychotherapist was perceived as being closed-off and impersonal. One group member’s experience bordered on reaching the intensity of a paranoid delusion, because this member proposed that psychotherapist 1 may have intentionally sat in front of a white wall each week to conduct a research study on how doing so might affect patients. This suspicion seemed to exacerbate the discomfort of other group members. Additionally, group members were concerned that psychotherapist 1 sat in front of a blank wall because he did not trust them, which was perceived as pathologizing. Nearly a year after psychotherapist 1 stopped facilitating the group, some group members continued to bring up thoughts and feelings related to what the coleader’s intentions and character might have entailed. When describing the former coleader to a new psychotherapist, one group member likened psychotherapist 1 to a private investigator who had infiltrated the group.

In comparison, group members praised psychotherapist 2 for occupying a space with art and plants that was described as visually appealing and calming. They reported that the background made them feel at ease and better able to engage in the therapeutic process. Group members also became excited when they were able to view a pet in the background of psychotherapist 2’s environment. Months later, one group member reported that knowing that psychotherapist 2 had a pet made this psychotherapist feel more accessible. Up to a year later, after the group had returned to in-person therapy, group members spoke about how different the virtual backgrounds were between psychotherapist 1 and psychotherapist 2 and how this contributed to detached and warm, respectively, personas.

Discussion

As seen in this case, the nature of teletherapy can significantly affect transference reactions and therapeutic relationships. In group therapy, dynamic administration is an important responsibility for group leaders. Dynamic administration refers to “attending to events at and beyond the boundaries of the group” through tasks such as tending to the physical environment. The therapist should create a setting that is safe and “free of worries about the physical environment,” which creates a “good-enough container” to allow members to address psychological issues (10). In teletherapy, dynamic administration changes and requires tasks such as technical assistance and ensuring that all group members are in private environments (10). While the physical “container” is broken when moving to teletherapy, this change creates a space for meaning to be created in different ways.

It is important to consider that individuals are affected by their physical environments because of their memories and past experiences, and the environment can influence behavior, emotion, and mental processes (11). As evidenced by this case, the virtual environment can cause similar influences, with the potential for rich exploration.

Teletherapy presents a complex set of changes for psychotherapists. Some of these changes can cause potential challenges, such as a loss of the supportive in-person environment in which patients can feel held and contained (6, 8, 12). In contrast, these changes can also lead to a different view into the patient’s world (both physically and mentally), a different type of comfort through distance, and new sources for meaningful transference reactions (6, 9, 12). As more psychotherapy shifts to online platforms, it will be crucial for psychotherapists to grapple with these issues in order to utilize the virtual setting in productive ways.

Key Points/Clinical Pearls