More and more frequently analysts are conducting treatment on the telephone. It can provide continuity in an increasingly mobile, even nomadic, world. Yet this is ironic, as a more sophisticated awareness of the significance of nonverbal communication is developing in the field. Eliminating the nonverbal dimension of communication creates difficulties for treatment. Reducing the channels available for transmitting and processing affect may impair the expression and detection of dissociated affects, especially with patients who have difficulty integrating affects with verbal expression. The absence of facial expression, eye contact, gesture, and movement interferes with the analyst's ability to attune herself with the patient.
The room's boundary encloses patient and therapist together in a shared space—a metaphor for physical holding. It provides a potential space as well as a real physical space that can contain intense affects. Replacing a shared, enclosed physical space with a telephone line can undermine the safety of a holding environment. Working on the phone may require therapist and patient to create rituals to protect the time and space of the phone session. The textures of tone, sound, and silence may come to replace the room as the physical basis of a holding environment.
Despite the hazards, working on the phone can provide opportunities. The telephone's simultaneous distance and closeness, separateness and connection can create a transitional space in which patients can work on their ambivalence about dependency. For schizoid patients, who long for and fear emotional connection and dependency, working on the phone can serve this therapeutic function.
This paper describes two and a half years of treatment three times a week with a woman in her late twenties. The first nine months were in person and the next 20 were primarily over the telephone. Working on the phone was a shield against fears of intrusion and emotional intensity, but by eliminating nonverbal communication, it created obstacles to meaningful contact that had to be overcome.
"It is joy to be hidden but disaster not to be found" in Winnicott's words (1963, p. 186). This was true for Serena, an articulate young woman whose words often hid dissociated aspects of herself. Physical expression felt most real to Serena. Yet most of her treatment has been over the phone. Serena was a dancer whose self-consciousness suppressed the passion she yearned to express and who searched for emotional closeness in short-lived sexual relationships. Her need to maintain distance and self-sufficiency disguised her wish to be attached and dependent. The longing for connection and fear of intrusion is the schizoid dilemma. My dilemma was how to make contact with Serena without impinging on her, and how to facilitate the emergence of unarticulated, hidden, dissociated domains (Bromberg, 1994) of her experience.
We had an easy beginning. She was tall and elegant, with a delicate face, soft brown eyes, and long auburn hair. In the first session she was thoughtful
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Publication information: Book title: Social Work Diagnosis in Contemporary Practice. Contributors: Francis J. Turner - Editor. Publisher: Oxford University Press. Place of publication: New York. Publication year: 2005. Page number: 691.
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