While I've been working during the covid-19 pandemic, there has been a rapid increase in referrals for work with patients outside the city that I work in, referrals particularly for remote therapy. A patient in Hyderabad needs a therapist, somebody in Mumbai needs a therapist, somebody in Kolkata needs a therapist. Can you work with this patient?

I am a clinical psychologist working in New Delhi. When I get these referrals, I often wonder if I should connect the patient to a therapist in their own city. My experience of my own personal therapy online is painful – there is a huge distance; technology is not enough to fill that gap. There is always an experience of a sensory deprivation. It always feels disembodied.

I am now comfortable with remote therapy, both in terms of providing it to my patients and my own “remote” and “long-distance” sessions. Given a choice though, I still very much prefer the warmth and the heat of the in-person sessions. As a patient, what I experience is a person breathing behind me, a person whose warmth has settled in, whose voice helps me when I'm alone, a room that I now call my own, parts of me which visit it inside my mind, when I'm disturbed. And so, this room that I now talk from, how is it the same as the consultation room? How do I call this working together in therapy?

Remote therapy is a painful experience. Nothing that I do can replace how fulfilling and wholesome the relationship feels when we're both in the same room.

So, when patients call from another city, I often feel confused. If I do have space to work with a new patient, I can take on a remote patient too. But should I work with a patient remotely? Often, my colleagues in other cities, are also now easily referring patients in their own cities. Geographical boundaries have been blurred, if not erased. I often end up wondering if I'm taking away an opportunity for this patient to have an experience of a wholesome relationship. Should they not have the chance to explore what it would feel like to be with their therapist in the same room? Can I be the one to judge whether I should take this away from them? 

It's become even trickier now. Boundaries are fuzzy. A therapist in America can easily work with a new patient in India. What if I need to refer the patient to a psychiatrist?

It is all blurry, the work is all blurry.

Remote therapy has its limitations. Our assessment consultations help us understand how best we can help our patient (Coltart, 1987; Milton, 1997; NIMHANS, 2020). Therapy helps us as patients and helps our patients to understand the reasons for each of our choices and this helps with the process of change, wherein the choice to do things differently is now upon the patient. Upon the arrival of this choice, we can decide to do things differently. At the birth of every therapeutic relationship, is a part of the patient that wishes to get better, that has known a good and healthy relationship in the past and that wishes to take responsibility for the choices that they make in life. It is our memory and our experience of something good that we have known before that makes us seek help. It is this part that we ally with when we work together with our patient. While working we always keep our omnipotent fantasies in check and remember the painful fact that we can’t ever replace the internal mother. However, what we can maybe offer our patient is gradual work that helps build on this good that they have known and experienced inside and help them confront their own destructiveness.

With a very disturbed patient who has faced incredibly early trauma, the distance in remote work can also be experienced as a violence that is far too difficult to bear. Psychotherapy might trigger a patient more and there may be a need of an intervention with help from an allying professional, like a psychiatrist, to be able to intervene and to help build a better frame for psychotherapy. Psychotherapy requires not just psychological mindedness but also a responsibility and a willingness to work together in therapy (Coltart, 1987). At one stage of our life, from an experience of having known goodness inside, we’re able to hold an image of the one we love inside our minds. In therapy, it is this that allows us to talk to the person behind us without being compelled to look at them behind. It is a painful experience because in that moment we must remain separate yet hold the person inside us. The comfort of the therapist in the same room allows the presence of a body to be felt. The consultation room becomes an internal home, whose images we carry, whose body and comfort allows us to breathe, to think. If this internal image, though, is not there to begin with, then remotely working can become a continuous experience of a phantom limb. Thinking about this pain without having a sustained internal image can be too demanding a task. Remote therapy poses far too many challenges.

At a conference that I had attended recently, there was a discussion about work during the covid-19 pandemic. The discussion was largely about the impact of covid-19 on our minds and our setting. A participant was then reflecting and talking about how people are rapidly beginning to work online and are easily taking on patients that they’re working with remotely. In jest, he then said, ‘By the looks of it, the dictum would soon be 'no memory, no desire, and no consultation room.'’

Everybody was splitting in laughter. I too laughed. His sharp and poignant point had pierced into my skin with joy. Listen without memory and without desire, but also now without a consultation room. 

It's become as simple as that. The value of the consultation room is depleted.

So, when patients in Kolkata, Mumbai or Bangalore call me, I too feel faced with a dilemma. I have respectable colleagues in all these cities. I can refer the patient there; they can work with a therapist who they have the option of meeting once the pandemic eases and once we go back to work.

If a patient calls me from another city, I try and offer that to my patient first. I let them know that I work in New Delhi and that our work will be online. If they tell me they're okay with remote therapy, at least both of us have begun the work acknowledging an already present gap.

In one clinical seminar, we were thinking about how patients looking particularly for remote therapy often also come with a history of neglect. We were thinking about how it's possible to provide remote therapy, but this also needs to be spoken about - the fact that therapy is now online. When we work with our patients, this remoteness begins to show up, that they feel a gap - and the gap needs to be acknowledged. This is where we are accepting that there is a lack, unlike perhaps their experience in the past where a lack and a neglect went unacknowledged. The acknowledgement of this lack would also maybe allow us to work with a possible history of neglect.

To be able to do this still, though, as a therapist, I need to acknowledge the sheer lack with which I am working. We need to be able to take responsibility for what we can provide and know what we cannot provide, know what we're taking away from the patient when we agree to work remotely and online.

Remote therapy especially now during this devastating pandemic is unbearable and hard. The concreteness of our setting sometimes doesn’t allow certain pathologies to surface (Polmear, 2020). Remote therapy can perhaps help to think more about absence. Remotely working and having to bear not being able to have a full and whole relationship, can also provide an opportunity to work through our guilt – the guilt of having damaged our significant relationships – and experience gratitude – experience the feeling of relationships continuing to exist with all the sorrow and all the joy.

It is only after a period of some separation that we can allow ourselves the entry of a third. Between a mother and a baby, it is only after an experience of some separation that the father can enter the minds of the mother and the baby. The mother and the baby can often get caught in painful positions and repetitive patterns; it is the father that comes in and allows the mother and the baby the relief of a third perspective. If the mother and the baby remain only a dyad – there is a perversion. With the entry of the father is the entry of the voice of reason. With the realization that we are the birth of a creative act between our parents is the birth of feelings of anger, along with feelings of guilt and gratitude. This shift in our feelings of our raging hate to our feelings of anger, guilt and gratitude can also only happen with the acknowledgement of a gap. (Klein, 1986; Money-Kyrle, 2014; Winnicott, 1971)

I do thus understand that remote work has its own charm. It is a different experience, and maybe it is a different kind of a relationship which still allows work to happen. But I am still sceptical of remote work. I would much rather prefer working with my patients in the same room. I also very much prefer working with my therapist in the same room.  

All this brings me to the question, what is the setting? Our setting symbolizes the union of the father and the mother. Our setting is a potential for the birth of something creative. Irma Pick (2018) has famously said that when we work with our patients, we need two hands: one to hold compassionately the needy and suffering part of the patient and the other to hold firmly and grapple with the hatred of thinking and feeling. And our setting is this union of two – our setting is the thinking heart that carries a potential for something creative, that allows a third to arrive and a new and different perspective to be born. Our setting indicates our patient’s relationship to the third.

The setting is also our internalized institution (Tuckett, 2020). Our setting is how we've internalised our institution(s), our many supervisors, and diverging schools of thought. Absorbing a different model of thinking, thinking about what a different school (of thought), a different mind, and a different therapist may have to offer, leaves us with the angst of separation. In that moment, the castrating fear is that everything you have known is being destroyed. In our consultation room this feeling shows itself when we are stripped of the only potency we have in the here-and-now – to think. Our desperate search for penetration makes way for sometimes a painful penetration in the room. We begin to rely on concretized words. It is from a painful experience of separating ourselves from thoughts we have known that we learn to enter the terrain of the unknown on this journey with our patients. It is from this separation that we allow ourselves to absorb something external and outside.

It is a separation that allows us to absorb different perspectives and sit with a multitude of views. Paradoxically, it is from our experience of feeling the war of diverging schools of thinking, touching the war of (professional) bodies, inside our minds, that we learn to abandon theory, so we can learn to work with our patient in the here-and-now. The setting is our internalized model of our institution(s) that we have experienced, felt, and known. And remote therapy is one setting, that also offers one such setting that we must together think about.

Remotely working, while it offers new experiences and opportunities to continue our work, still feels new. I wonder about how, now that we are smoothly making a transition to providing more and more remote therapy, if this too is like a "new strain.” What is our consultation room now? What is the new setting? I suspect that we would have to spend a lot more time thinking about and understanding this new strain and this new connection. For now, I suppose we listen without memory and without desire, but we also keep in our minds, our consultation room. And by doing that I wish we sit together and engage in a creative act – think about our consultation room, think about our work and what it means to work now with this new connection.

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