Dear Dr. Longo,

I am sending you a copy of my paper on Telephone Analysis. I am very happy that you are interested in reading it. I have a special fondness for Italy. I lived in Firenze for a year and a half and then many years later I lived in Roma for another anno e mezzo.

Warmest regards, Sharon Zalusky

Past traditions and prejudices have precluded many analysts from openly considering the use of the telephone in psychoanalysis. However, increasingly and to varying degrees the telephone is becoming an important part of every analyst's clinical practice. The use of the telephone in clinical practice evokes complex feelings and raises a number of important issues both for the patient and for the psychoanalyst.
Telephone analysis most often represents a therapeutic compromise, and because of this, it is inherently conflictual. However, it may also represent during a certain period in the analysis the best treatment available for a particular patient. Not to offer a continuation of psychoanalysis by telephone may itself represent a transference-countertransference enactment.
This paper will deal both with the analyst's and the analysands' initial resistance to telephone analysis. Guilt experienced by the analyst for deviating from traditional psychoanalytic norms as well as for depriving the analysand of a "full" analytic experience will be explored. Corresponding feelings of shame in the analysand for continuing to need the analyst will be discussed.
Two cases of telephone analysis will be presented to illustrate the poignancy of initial telephone contact, issues associated with the decision to do psychoanalysis by telephone and some of the paradoxes and complexities of telephone work itself. Modification in technique and its applicability to psychoanalysis in general will be discussed. Because this paper is meant to be a preliminary communication, its purpose is to stimulate thought and raise additional questions.
The Telephone in Clinical Practice
For most analysts in private practice the telephone is often the first introduction to one's patients. It is the beginning of the assessment process. Before patient and analyst have ever met, the potential for a therapeutic relationship is already being considered. Each party is responding to each other's voice, verbal demeanor, and ease at establishing an appointment time. Initial transference-countertransference reactions and enactments are often set into motion. Both analyst and patient hypothesize consciously and unconsciously about the availability of the other to engage. All this happens prior to either party laying eyes on each other. Information gained on the telephone is then utilized to facilitate the initial encounter. We take this all for granted. We even rely upon it.
The telephone has long been accepted outside analytic circles as an important therapeutic tool it its own right. Its use in crisis intervention, suicide prevention and community hotlines is well documented (Brockropp, 1976). It has been discussed in the literature as an emotional safety valve. The telephone has also been considered in treatment with severely anxious, regressed and unstable individuals who find therapy in person too threatening (Grument, 1979). It has been found to be effective with adolescents who would not ordinarily come in for treatment (Zalusky, 1988).

The telephone in psychoanalysis

Apart from a few notable exceptions (Saul, 1954; Robertiello, 1972 and Lindon, 1988) the potential use of the telephone in psychoanalysis has not been discussed as a viable treatment option. As analysts, our attitudes about the telephone in clinical practice are often quite complex. We each have a private if not public position towards the use of the telephone and its limitations. Some analysts encourage telephone calls in between sessions, others accept them, and there are those who refuse telephone contact except for scheduling purposes. Each analyst, if asked, presumably has a well thought out theoretical rationale for the use of the telephone as an auxiliary function to analysis in between sessions. The same analyst, however, may be more conflicted about its use for entire sessions which are held over the telephone at times when the patient cannot physically attend because of illness, is away on prolonged business trips, is unable to come into the office during or after pregnancy, or is moving and prefers not to transfer analysts.
The use of the telephone in clinical practice evokes many feelings and raises a number of important issues both for the patient and for the psychoanalyst which have not been adequately addressed in the existing sparse literature. Privately, one hears almost in a matter of fact way, "I can't talk to you now. I'm about to have a phone session with a patient." However, that seems to be the extent to which this matter is ever discussed. It is as if telephone sessions may only be revealed to one's closest friends and colleagues. The subject of the telephone in analytic practice is not brought up in seminars and is rarely ever written about in case studies. One can easily get the impression from its absence in discussion that telephone work does not exist except in the rarest of circumstances. My experience with my colleagues suggests otherwise. The use of the telephone in psychoanalysis, though certainly not an every day occurrence, does take place far more than the literature would suggest.1
Those who have written about the telephone in psychoanalysis have done so, portraying its use in only a positive light without discussing some of the more problematic issues. Both Saul (1954) and Robertiello(1972) report using the telephone as a technical aid in actual psychoanalyses with patients whose intense regressed transferences have precluded productive analytic work to occur during sessions. They believe without its use analytic work would have had to been terminated. Lindon (1988) has recorded the most extensive use of psychoanalysis by telephone. His experience has spanned over twenty years. He has conducted some analyses over the phone for short periods of time, several for three year periods and one for more than five years. Lindon reports that most of these patients who were analyzed by telephone did so because their work made it impossible or impractical for them to come for sessions in his office. The telephone allowed their analytic work to continue. Without it, the analysis would either had to have been disrupted, transferred or terminated.
Like most who write about psychoanalysis or psychotherapy by telephone, Lindon was surprised how easily analytic work could proceed over the telephone as long as the analyst perseveres in the mode of analytic listening. In many cases Lindon believes the analytic material is indistinguishable from an analysis taking place in his office. He reports recommending psychoanalysis by telephone to colleagues who concurred that analysis can continue by telephone. Lindon states that it is often more difficult for the analysts to adjust than it is for the analysands. Though he does not elaborate why that may be the case, it is my hypothesis that the analyst's unanalyzed loyalty to past traditions, at least initially, may be continuing to exert its influence.
Building on Lindon's work I will attempt to explore the complexities and paradoxes involved when analysis is conducted with only the verbal realm available. Though I agree with Lindon that if given verbal transcripts of sessions, often it would be impossible to differentiate the telephone analysis from the one occurring in the office, I also believe it is equally important to add that the two experiences are not the same for either the analyst or the analysand. There are essential differences and unique challenges. Each deserves its own consideration.
Starting with the premise that telephone analysis most often represents a therapeutic compromise, it rarely, if ever, is the treatment plan of choice. In fact, more frequently than not, patients who leave town interrupt, terminate or transfer to another analyst and the question of continuing the analysis by telephone is never actually considered. Undoubtedly there are also some analysands and some analysts for whom psychoanalysis by telephone may represent a resistance to experiencing the emotions created by absences, and for them it would not be well-advised. However, I do believe there exists a group of patients who may be in a particularly sensitive and transistional phase of an analysis where a continuation of the analysis on the telephone may very well represent the best treatment available at that time. Not to offer or to explore a modified continuation of the analysis by telephone may itself represent a transference-countertransference enactment.
I chose to emphasize the essentially conflictual nature of telephone analysis, not because I am opposed to this therapeutic modality, but because I believe that by recognizing its inherent complexities we can add to its potential effectiveness. It is my belief that embedded in the communications of both analyst and analysand is often a conscious and unconscious recognition of what each gains and loses by doing the analysis by telephone. I hope to show that transference-countertransference feelings evoked by the differences when analyzed often offer insight into the internal world of the analysand.
Below I will present two cases of telephone analysis. In each case the patient had been repeatedly traumatized throughout childhood and adulthood by either emotionally unavailable or unstable parents. I hope to show that a continuation of treatment on the telephone represented a needed holding environment. The ability to maintain consistent emotional contact with the same analyst, rather than interrupting or terminating treatment, created an analytic space where the patients' transferences were able to be analyzed and worked through. The work on the telephone helped both analysands to develop a greater sense object constancy and consequently a more solid sense of their own self.

CASE A

I offer the case of Annie because she and I both have struggled and continue to struggle with feelings stirred up by our telephone contact. Because the telephone and all the fantasies evoked by its use have become the central focus of this analysis, this case offers us a unique opportunity to examine in depth some of the basic issues surrounding telephone analysis.
The decision to continue her psychoanalysis by telephone was not an easy one to make. It evolved over time. I will present material from three different periods to illustrate (1) the poignancy of our initial telephone contact, (2) the conflicts associated with the decision to continue psychoanalysis by telephone and (3) the complexities and paradoxes of telephone work itself.
There has been a continuous interplay between the real logistical considerations, our transference-countertransference resistances, and the unconscious meanings attributed to them. We have analyzed and have grappled with some of the positive along with some of the negative implications of this form of treatment. Our task has been facilitated by the unique attributes that this particular analysand has brought to the work. She has a special history being a child of divorce who is used to telephone communication with one parent or another. She has a highly developed verbal self which is coupled with an openness and devotion to understanding her unconscious and an insistence that I do the same.
The Poignancy of the First Telephone Contact
Annie, 41, is a bright, energetic, enthusiastic African-American woman who came to treatment prior to breaking up with her boyfriend of many years. During our first session which took place the day after our first telephone contact, Annie reported the following dream:
I am at the seaside. I dive into the water and deep underneath, there is a box that I bring to the surface. I look inside. There is this weird frightening creature. I want to close the box. Then I see this woman who is a marine biologist. I take it to her. She isn't frightened by what she sees. She tells me, "I'll help you look inside. You don't have to be frightened of it either." She seemed curious about its nature. Next, I'm with her and my family and we are in the desert. Off in the distance is this miniature house which I recognize as my house from childhood. It's not entirely constructed. We all go together to take a look.
I present the dream to underline, from a psychoanalytic perspective, the poignancy of our first telephone encounter. Prior to having ever set eyes upon each other, Annie and I were already beginning to respond to each other's tone of voice, choice of words, and general level of responsivity. In reassessment of this initial dream with the benefit of having worked together for many years I suspect that during our brief telephone conversation prior to our meeting, I must have responded to Annie's distress in such a way that allowed her to know that she could create me as a guide to take her on an analytic journey into the depths of her unconscious and back to her childhood in order to finish the "construction of her house." Transference-countertransference fantasies were being stimulated in anticipation of our first session. A sense of hopefulness evoked from the telephone contact presumably linked up with Annie's need for a caring maternal figure which seemingly may have generated the dream. In like manner our initial contact must have encouraged in me a certain receptivity to be the guide for whom she was searching. Verbal contact alone was and continues to be a powerful medium which activates these kinds of fantasies.
During our first session together we both knew her dream had significance and repeatedly we have returned to it. What we were unaware of at the time was that our way of verbally relating to each other might have already been predictive of our ability to do a psychoanalysis by telephone.

The Decision to do Psychoanalysis by Telephone

Through the analysis Annie became aware of her own needs and desires. She discovered a personal passion, a career she wished to pursue. With the same intensity and dedication she employed in the analysis, she prepared herself to apply for graduate school in a field in which she had no prior experience. Due to her perseverance she prevailed much sooner than either of us would have predicted and was accepted into a prestigious university in another city long before her analysis was completed.
The possibility of this important perhaps monumental change created in Annie a state of intense conflict. Within three months she would have to leave a job, a home she created for herself, and an analyst to whom she was deeply attached. This was particularly problematic for Annie given an early and repeated history of emotional deprivation and loss which manifested itself early on in the transference by an acute and continuous sensitivity to my presence and availability. As she prepared to leave memories of a repetitive childhood nightmare of being left in the care of a ghost baby sitter returned. These memories were reminiscent of the opening phase of her analysis, when she could barely count on my physical presence. During those early days at the end of each session Annie would take out her date-book and reconfirm the next day's appointment time with me. When this pattern was analyzed, we discovered that Annie was afraid that if she did not actively remind me of her sessions day by day, I might not remember to come. But even more profound Annie feared I might not remember that she existed.
After many years of intense work it was no wonder that Annie experienced her acceptance into graduate school as a mixed blessing. It represented a tremendous sense of fulfillment and personal growth. However, it also meant that she would have to leave her analysis. We both analyzed the meaning of her early termination. I paid a great deal of attention to my countertransference feeling of pride in her achievement. I wondered whether I was reenacting an old family theme of hers: the overglorification of academic accomplishment without sufficiently weighing the emotional toll it might take on her. We explored what this achievement meant. It was not to please me. She had finally found a career that resonated with her view of herself. Her trepidation was more about leaving, and less about her destination.
In the end Annie decided the opportunity was too great to miss. If it proved to be the wrong decision it would not be irreparable and she could return. We both, however, recognized she was in the middle of the analytic process. We were confident that one day she would continue her analysis. At that time neither one of us considered psychoanalysis by telephone. It was not an option.
As the move became imminent, Annie's anxiety mounted, bringing forth more childhood memories of repeated location changes. With each change, she remembered how both she and her mother had withdrawn deeper and deeper into a depression, but one that was masked and never discussed.
Now as her excitement was beginning to shift to fear Annie asked if we could have twice a week telephone sessions while she traveled to her new destination. She told me that she did not want to submerge her feelings this time. Instead she wanted to stay connected to me. Hesitantly, without time to analyze in depth the meaning of telephone contact I agreed, but only as a transitional phase. I told her I had my concerns. I had never done telephone sessions. I wondered whether I would be able to maintain a sustained connection over the telephone. I knew how much she relied up my emotional availability and how sensitive she was to any deviation from the optimal. I told her I did not want to recreate the ghost baby sitter of her childhood nightmare. However, I did not want to abandon her either. After considering the options, we both agreed to give it a try, recognizing she might be disappointed.
In an ideal analytic world we would have had the opportunity to either terminate our work in a more timely fashion or analyze in depth what her request meant, but as Renik (1994) suggests sometimes we act first and analyze later. Today because analyses spread over many years, life intervenes in our work. People become ill. Pregnant women may have complications that require immediate and prolonged bed rest. Spouses need to move for business purposes. People lose their jobs and need to relocate. We, as analysts, have to take the patient's needs into account. Sometimes we must offer creative solutions to such exigencies and analyze their meanings to the analysand and to ourselves after the fact. And that is what we did.
Annie and I worked out a schedule where she would call me twice a week at a regular appointment time. Within a short period it became very clear that Lindon (1988) in his article on telephone analysis was right. The tone of our sessions was almost indistinguishable from our previous work. Her transference to me did not disappear because we were talking on the telephone. Instead, ironically I was more present to hear the nuances of her associations. Because I had no visual interference, I could more easily follow Freud's (1912) recommendation to turn my "own unconscious like a receptive organ towards the transmitting unconscious of the patient (pp. 115-116)."2 With only my auditory sense available, I was able to hear her differently. Annie's basic good nature, her enthusiasm, and her delight to be in the room with me could no longer mask the depth of her pain, her loneliness, and her depressed affect. The telephone tended to facilitate unconscious to unconscious communication. Annie, too, became more sensitive to my moods and commented on changes in the tone of my voice, longer or shorter periods of silences, etc. We were able to explore what these shifts meant to her. Through these telephone sessions we were refining our level of attunement to each other. It was surprising how easily affect was transmitted through the telephone lines.
In fact, I have found some other advantages to doing work over the telephone. Like Freud (1913) who felt the couch freed him from the gaze of his patients, I, too, was freed to walk around my office with my phone. I suffer from a back problem and while sitting all day, I am always faintly aware of my pain. Paradoxically, I was freer to be there with her. I also felt a greater responsibility to be present. If all I had to give her was my attention, I quickly became aware when my mind would wander and would analyze my own contertransference. Our work was continuing. Annie was still associating and I was still analyzing.
However, I began to notice something curious. Though we both valued our sessions on the telephone, neither one of us broached the topic of formally continuing the four day a week analysis by telephone. I began to question why was I not offering her a continuation of a treatment from which she greatly benefited in the past and why was Annie not asking for it. It was clear that she wanted more and more contact in between sessions, but not sessions themselves. I wondered were we in the midst of a particular transference-countertransference enactment; was there something about telephone analysis itself that we were both resisting or were the two somehow inseparable at this moment.
First, I attempted to analyze my own countertransference. The predominant affect I was defending against seemed to be guilt. It was, however, complex. On the most superficial level my guilt seemed to be about violating some unspoken analytic rule: you do not analyze by telephone--you transfer. I wondered what would my colleagues think. Would they assume it was I who was encouraging Annie to stay tied to me in a regressed dependent way? In fact, Annie would often raise that possibility herself, but she did so hoping that I would need her as much as she needed me. But was there truth to it? Or was that concern part of a complex transference-countertransference paradigm that prevented me from offering her what she could not ask for herself?
I wondered if I should try harder to get her to transfer to a local analyst. When I would bring up the possibility, Annie would tell me how disruptive that would be. As we continued to analyze her feelings, she elaborated that she had already lost so much: her friends, the home she created, the consistency of her daily life. Annie would tell me that she could not bear to lose me too, not now. If she would see another analyst, all she would talk about is her loss of me and she needed help dealing with everything else going on in her life as well. Annie explained that she did not need just any analyst to be there with her, she needed her trusted analyst. Annie insisted that now was not the right time. I sensed she was right. Transferring patients in the best of circumstances is often complicated. But in this particular case where there had not been an adequate termination phase, I felt it would be experienced as if I were abandoning her just as she began to explore her own autonomy. To transfer her, because I felt guilty about transgressing some abstract analytic norm, would have been an enactment on my part.
Though I knew she needed more than twice a week therapy, I still did not suggest increasing our telephone sessions. I continued to analyze my own resistance. Doing so, I realized I also felt guilty for other reasons which I considered purer. Would I not be depriving her of a full analytic experience? In recognizing and valuing the importance of the non-verbal aspects of analysis, we would be cutting out a very essential component of our work.
I raise the issue of my own guilt because I believe I am not alone in having these feelings in relationship to telephone work. Otherwise I suspect that we, as analysts, would be more open to talk with our colleagues about a phenomenon that is not all together rare. I think most analysts who consider telephone work must contend with the guilt of depriving the patient of visual contact and many of the routines that have become a part of analytic work. There is something comforting and reassuring for the analysand to know that their analyst is behind them, literally seeing them through the difficult process. There is the routine of traveling to the office, waiting in the waiting room, settling into the couch and then getting oneself together to leave. All this is cut out from a telephone analysis. We, as analysts, are used to providing a safe environment, both physically and emotionally for our patients. But during telephone analysis we must rely upon our analysands to provide this for themselves, and sometimes they may have difficulty doing so. In addition, our contact though still vital and important, is nonetheless indirect. Our voices first need to travel through cables or optic fibers. Even when video monitors will be available it will never be the same.
I imagine that those analysts who portray telephone analysis as almost indistinguishable may also be defending against their own feelings of depriving their patients. When we call the work indistinguishable, it seems that we are reassuring ourselves. There is no way around that fact that we offer a compromise when we do telephone analysis. If we are not open to that ourselves, it would be difficult to analyze the feelings and the meaning of that compromise to our patients. I believe that the fact that we are making compromises or accommodations is not as deleterious to the process as the denial that we are doing so would be. Accommodations at the right moments are a part of every healthy relationship. They are unavoidable. Not to be able to adapt to special needs is a form of rigidity. It is a way of elevating principle over context.
As I became clearer in what was blocking me from offering an analysis by telephone, I began to realize that my ambivalence perhaps was depriving my patient of something more profound, the possibility of the best treatment possible for her at this particular time which was a telephone analysis. In many ways it is not that dissimilar from what children and parents of divorce have to contend with. Annie may not have had me in full sight, but I was still there as an emotionally available person who did not want to abandon her during her difficult and stressful journey. We would both have to learn to be there for her in new and different ways in order to help her continue to grow (Zalusky, 1995). In retrospect I recognize the fact that while I was there struggling along side her, trying to decide what was right for her and for me, we were creating a new experience that contradicted Annie's old transference belief that neither she nor her needs would be considered.
Now that I had shifted internally, I was free to help her analyze what was behind her resistance to psychoanalysis by telephone. We both could "see" that she did much better when she was in contact with me four days a week, even if two of them were just to touch base in between sessions. I think it is important to clarify that it is not only the number of days a week that makes a treatment an analysis. Analysis is about analyzing transference, countertransference, and resistance. In Annie's case she needed the consistency of four days a week to create a safe holding environment in order for us to do the work of analysis.
As we explored her resistance to increasing the number of sessions the following emerged. Annie feared that her family would interpret her attachment to me as being disloyal to them. Being the child of divorce the transference implication was clear. She also feared that they might view her dependency on me as a sign of weakness, and then they would be disappointed in her. Annie then began to acknowledge that it was not only her family, but that she, too, was disappointed in herself for not being able to function as well without consistent contact. If guilt is the affect with which the analyst is struggling, its corresponding emotion in the patient may very well be shame over continuing to depend on the analyst.
I interpreted to Annie that it may seem threatening to her to acknowledge her own needs, when her needs seemed to diminish her in the eyes of the people upon whom she relied. She denied her own needs even to herself in order to maintain a sense of safety within her family, but she was suffering. It became clearer that we were both involved in an elaborate transference-countertransference enactment. Because of my own unanalyzed guilt, I was colluding with her in her denial of her own needs. I was like her parents who did not want to see the extent to which their divorce (absence) caused her pain and even disorganization, and thus by not acknowledging it, could not adequately offer her the help she needed to get through her distress. By talking to her two days a week instead of four I was also reenacting her experience of her mother moving emotionally farther and farther away.
I was certain that her move had triggered a regression. I did not see her wish to stay attached to me as a sign of pathological dependency. She needed, however, to feel the consistency of our established relationship to help her through her important life transition. We both recognized that it was because of the considerable work Annie had done in the analysis that she was able to push ahead with her life, to take on new risks.
After analyzing both her transference and my countertransference resistances, the four day a week analysis was resumed by telephone. Immediately our work deepened. We were able to deal with issues surrounding her parents' divorce in an affectively charged way that we had heretofore only discussed intellectually. The telephone itself took on new meaning. Annie could remember the many intimate moments she spent with her father on the telephone. We were beginning to deal with what it felt like not to have her father physically present. She described how she experienced his moving as a tremendous loss given her father was the parent who made her feel alive. Annie remembered feeling dead inside as a child, after her parents' divorce. There was so little stability in her life, and there was no one to help her appreciate what suffering she had endured because of it.
Our telephone analysis represented a powerful holding environment for her. No matter where she was she could always maintain connectedness to an emotionally present person, even if I was in a distant city. Our work on the telephone paradoxically increased her belief in my availability which has corresponded in what seems to be an ever increasing sense of object constancy and its consequent impact on her own sense of self. In addition to internal gains, she is doing well both academically and socially.
At times I still wonder whether perhaps we are both involved in a folie a deux in an attempt to deny our loss or that we are reenacting an early childhood trauma. Parenthetically, I suggest this is what makes telephone work so difficult. Recurrently, as analysts, we inevitably face the question as to whether at times we are appropriately analyzing the material or whether we are only colluding with the patient to avoid what needs to be analyzed. In telephone analysis, however, this conflict is omnipresent and is experienced by both parties at different times with varying intensity. As analysts, we want to offer the best service possible. Recognizing the exigencies of the situation, the feelings evoked are not unlike the feelings of divorced parents or working mothers where there is constantly the balancing of gains versus loss.
The Complexities of Telephone Analysis
I think what is most interesting theoretically about the work on the telephone is that in some ways it focuses and condenses some basic issues of psychoanalysis like the analytic frame, separation, loss, availability, the needs of both analysand and analyst, and deviations from the frame. Because of the concrete expression of some basic analytic concerns it presents us with the challenge of thinking through some technical considerations. I want to offer the following vignette from my work with Annie to elaborate on additional paradoxes and complexities of telephone analysis. I will concentrate on two areas: (1) the needs of the analyst and (2) the transference and its special significance in this modified form of treatment.
Recently after a period of time during which Annie spent much of the analysis dealing with her intense longing to see me, wondering what I now looked like, fantasizing about me, she tells me that she is going to visit a friend in a city not very far from Los Angeles, but makes no mention of wanting a session in person.
At first I am a bit surprised, but I find myself unable to explore this contradiction with Annie. I know her well enough to know that by the way I feel blocked we are involved in yet another transference-countertransference enactment. Embedded in it is the interplay between her dynamics, my dynamics and realistic logistical considerations regarding telephone analysis. The issue of acknowledging needs has always been a focal part of her analytic work. As I begin to unravel it, however, I realize that I am having difficulty exploring this issue with her, because I do not want to impose my needs on her. I try to play with the idea, asking myself what would it mean if I want to see her and she has no need to see me. Beyond the personal meanings, it would raise an interesting technical consideration in doing telephone analysis. Could it ever be a necessary consideration that the analyst may need from time to time to have sessions in person, even if the analysand does not appear to have that need? I imagine it could be. We, as analysts, often have needs that are gratified (Renik, 1993), but usually those needs have been integrated into the formality of analysis itself: a need to be helpful, a need for a consistent schedule, for a certain fee that is paid on time, etc., but these needs are often hidden. They have been so legitimized and accepted as part of the frame that they often go unanalyzed. But in this case however, the analyst's need to see the patient would have to be openly acknowledged for what it is. Ordinarily, we interpret to the patient that coming to sessions is for the benefit of the patient, but here paradoxically it may also be for the benefit of the analyst to continue to be able to do the work.
Bacal and Thomson (in press) offer a convincing rationale for accepting this as a potential condition when they speak of the analyst's need for optimal responsiveness by the analysand. They contends that the notion of reciprocal sustenance is at the core of any viable therapeutic process. Once I could accept this possible need of mine to see her as legitimate, I was able to wonder out loud about the transference implication of Annie making no mention of coming for an office visit. It freed me to explore her needs. As we analyzed her feelings about her trip, layers of meaning were discovered. The first was her conscious anxiety that she would have to see too many people in too short a period of time, and consequently would have no time to enjoy her trip. But just beneath the surface was her fear of seeing me. Annie described feelings she had during a prior visit. She explained how alien it felt the last time she saw me. In fantasy we are always extremely close, then when she actually sees me I am different from the person who is with her on the telephone. There is paradoxically an intimacy of physicality, she explains, on the phone. It is not sexual, but a profound personal sense of closeness. Annie describes that we are like wall paper on the wall familiar when we talk without seeing each other, but then she sees me and I don't look like me, the perfect me she has created. The first twenty minutes after finally being in the room with me are jarring to her psyche. Then she adjusts for five minutes, but the remainder of the session is spent feeling sad, Annie explains, because she remembers what she is missing. It stirs up a hunger and longing and a knowledge that she can't see me when she wants and then she feels like she is missing out. Immediately after, she feels like she is being indulgent because she truly wants to see me all the time. The evening after we begin to explore her longings she dreams that she is having sex with a woman. The erotic components were analyzed along with the sexualization of hunger for contact.
I present this material because it speaks to the complexity of the transference. At times telephone analysis can serve to intensify rather than dilute the transference as has often been suggested. If the couch serves as Freud (1913) suggests as way to induce regression where the analyst as a person does not interfere with the development of the transference, then the telephone is a vehicle par excellence for this motive.
Many, perhaps most, analysts today believe that the transference in varying degrees is co-created by the personality of both the analyst and analysand. However, over the telephone reality seems to play less of a role in mitigating the internal world of the analysand. If in a regular analysis the analysand fantasizes that his analyst is as sexy as Marilyn Monroe, as he arrives or leaves the session, he may not be able to escape the fact that she looks more like Hillary Clinton. Another time after being angry at his analyst, while he leaves he can not help but notice that his analyst continues to survive his attacks intact and may even have a smile on her face when he arrives for his next session. Somewhere these types of non-verbal knowledge may be an important aspect of the resolution of the transference. It is clear that verbal interpretation may even be more important in telephone analysis than it is ordinarily. In addition, it raises an interesting question about the possible relationship between perceived reality, transference and the ability to work through.
Transference though intensified may also be more hidden in telephone analysis. We have no visual cues to alert us. Though some have implied that the erotic component of the transference may be diluted, here again it, too, has the potential to be intensified, yet concealed. Also the possibility of acting out (coming to session drugged or naked, etc.) without the knowledge of the analyst is increased.
The unique challenges posed by telephone analysis are not insurmountable, but I have found that they require an adjustment in technique. I feel it enriches the experience when I take a more active and inquisitive stance. When applicable, I have found it helpful to ask more questions regarding possible transference implications. An example of this is I often actively inquire about her setting. Where does she conduct the analysis? In what room of the house and under what conditions? Does she have fantasies about where I am or what I am doing? She also often volunteers her fantasies regarding my locality. At times Annie has dreamed that we were both in bed together. There can be an erotic component in talking on the telephone. It as if we are talking together in the dark, a form of pillow talk. At another time when I was particularly silent, she had the fantasy that I was distracted, browsing through a Victoria Secret's catalog. When analyzed, we gained insight into important genetic material.
With this type of treatment I have had to rely more heavily than I ordinarily would on my own intuition or feelings. In doing so, I offer my interpretations in a spirit of collaboration. I have found this helpful which has influenced my work in general.
In addition, I have discovered that it is important that if Annie notices something in my voice like sadness, after exploring her fantasies with her, I tell her to the best of my ability whether or not I am actually feeling the way she has perceived it. I often add verbally the visual cues that she cannot see. And she tends to do the same. It seems to be helpful and serves to open up the analytic work, rather than foreclose it.
Overall, telephone analysis can be both challenging and rewarding. Though at times still conflicted, I am confident that we are doing meaningful work and that Annie is benefiting from our telephone contact. The analysis is helping her establish herself firmly and confidently (both internally and externally) in her new community. We continue to analyze what it means to her not to be able to see me. Ironically however, her pain has more to do with me not being able to look at her. Often when we talk about object constancy we are referring to the analysand's ability to maintain a mental representation of the other. But it is my experience that tremendous pain comes from the analysand's belief that she will not be remembered by me when she is not concretely in front of me. Telephone work offers a unique opportunity both to elaborate on the fantasy that the analysand ceases to exist for me outside my gaze and to inadvertently create a desired corrective emotional experience. My analysand knows concretely that she continues to exist for me. She learns that she may be out of sight, but she is not out of mind.
Currently, we are analyzing the possibility of terminating her analysis with me. Annie no longer experiences the thought as an abandonment, but rather a sign that she has grown. She has sufficiently internalized my presence which is beginning to make the thought of separation possible. Annie is convinced that eventually she will return to the work of analysis with an analyst in her own city.
This raises the question, what constitutes termination in telephone analysis? Is it similar to the usual termination process or does it mean the ability to transfer successfully to another analyst? Presumably, termination in telephone analysis will take on varied meanings according to the different needs of the analysand and the particulars of the analysis. The logistics of termination whether it takes place on the telephone or in the office also need to be explored. In Annie's case we have decided that the actual termination (the last few weeks of the analysis) will take place in my office.

CASE B

Finally, I want to present another shorter case where after having worked through many of my own resistances to telephone analysis I was better able to analyze with the analysand a central transference resistance.
Bobby, 40, is a single man I have been seeing in analysis for three years. He began his analysis soon after his parents with whom he had had a difficult and ungratifying relationship had died. On the day of their death Bobby ceased to have any further communication with his many sisters and brothers.
Throughout Bobby's life both parents appeared to have suffered from severe emotional disturbances. Many years ago he had been a patient of mine in psychotherapy and found it helpful. He returned to treatment when he began to regret that he had never developed a meaningful adult life for himself. Bobby had stayed his parents' child. He did not date. He made no home for himself. His relationships both at work, with his friends and siblings were tumultuous and unsatisfying.
After his parents' death, Bobby wanted more for himself. He wanted to begin to live his life for the first time. He began analysis with a sense of hope that things could be different. Bobby was right. Within a few years he had already made remarkable changes. He created a home for himself. He worked hard at cultivating good and caring friends. He began to date again. And finally because his relationships with people were so much better, his career began to take off. His work meant a lot to him, because it signified in a concrete way that people noticed the changes he was making inside. He began to respect himself and others, and they were reciprocating. But underneath it all, Bobby did not believe he mattered to anyone, especially me.
At this same time ironically his actual position was in jeopardy because of corporate downsizing. One day Bobby came to the analysis full of pride telling me that he had been asked to interview for a job that would take him outside of Los Angeles for a year. This new position would be an unusual opportunity to expand his repertoire and provide him with a special expertise in his field. Yet other than being pleased to be asked, he seemed relatively uninterested. Much to my surprise Bobby was not pursuing the opening. It was striking given that Bobby works in a field where there are few positions and little possibility for this type of promotion.
I began to analyze with Bobby, his resistance to his own advancement. At first he stated that he did not want anything to interfere with his analysis. He did not want to abandon his treatment now. It was much too important to him. Ordinarily, as analysts, we would consider that to be reasonable. Bobby seemed to be an analysand who valued the internal over the external. Because I had now accepted the benefit at times of telephone analysis, I felt comfortable suggesting that he did not have to terminate his treatment. That was not the only option. I mentioned the possibility of continuing his analysis over the telephone. Bobby was still uninterested. He told me that he was appreciative of the gains he made through his analysis. He had never felt as emotionally strong before. He had no intention of leaving, even though his position at work was in jeopardy.
Obviously, I knew he was right to believe that his analysis was instrumental in his changing perception of himself, however I continued to experience his reluctance to even fantasizing about the idea as a resistance. Because of my conviction that he could continue to grow analytically, even if he were not in the same city, we continued to analyze this situation. The unconscious resistance became clearer. Not to leave, but to stay close to me would represent a repetition of how Bobby gave up his own life for forty years to be near his emotionally unavailable and unstable parents. Unconsciously, he believed that it would damage our relationship if he were to feel excited about the possibility of this new experience. But mostly, if he were to leave, he believed I would cease to remember him.
After analyzing the transference implications, Bobby felt freer to follow his own desires. He chose to take the job which began almost immediately. We examined the alternatives (taking a hiatus, transferring to a new therapist for a year, and telephone analysis) and concluded that continuing the work we were doing over the telephone would be the most productive and the least disruptive. We both viewed his ability to sustain his connection to me while moving out on his own, and pursuing his life goals as a therapeutic gain. It was both a liberating and integrating experience for Bobby to discover that he did not have to disconnect, the way he has always done in the past, in order to move forward.
Bobby has been gone for eight months. The analysis continues. At first he was nervous about his ability to stay related with me over the telephone. We had worked very hard to develop a connection at the beginning of his analysis and he feared that would be compromised. Again, that proved not to be the case.
Bobby is happy at his new job in an exciting city. During one of our sessions in which he found his new position trying, yet rewarding, Bobby spoke about how grateful he was to be able to continue the analysis over the telephone. He stated, "I've never been able before to maintain my self-esteem and self-regard under moments of stress, the way I am doing so now. I know this telephone work is helping me. I don't think I could yet do it without it. I haven't had a lot in my life to count on. It is reassuring to know this is something I can count on. My parents didn't mean to be nuts. They just were.....I wouldn't have been able to start a new job, find a new apartment, make new friends and have a new therapist too. I feel good learning that I deserve more. I know I deserve to be able to count on someone. And that I can have what I want."
At first as I listened I felt touched that our work was helping Bobby maintain his self-esteem, however I was also struck by how I, the analyst, was left out. Bobby articulated that it was the telephone work that was helping. He did not say it was our relationship, our joint analytic work - it was the telephone work that was helping, that was reassuring. As I thought about it, I began to realize the telephone work for Bobby seemed to represent a transitional object for him in much the same way Winnicott (1953) discussed the phenomenon. His telephone analysis protected him from being overwhelmed as he ventured out into the world. It was helping him separate from me while still having me available. It also facilitated in him a shift in his own perception of himself in relationship to me.
Recently, Bobby has begun to experience dependency longings for me. He is proud of those feelings, knowing that something important has changed inside him. He explained, to consciously experience his need for me means to him, that he trusts in my availability. He told me that for many years he could not believe the I could or would care for him. Bobby says for the first time in his life he takes it for granted that there is someone, his analyst, who cares about him. He explained that the fact that I continued to remember him in his absence has had a profound influence on how he feels about himself. With a recognition of his own worth, for the first time in all the years I have known him, Bobby has finally begun a very important romantic relationship with a woman.
Ironically, the more Bobby feels me as a presence in his life, the more the telephone work feels inadequate to him. Bobby explains that I am becoming more of a real person for him. Recently we have made an adjustment. Bobby wants to come back once a month for sessions in my office. The analysis in the consultation room will continue when he returns before the end of the year.

Discussion

It is impossible on the basis of two cases alone to make broad sweeping generalizations about the efficacy of telephone analysis. However, in relationship to my two patients, I believe that telephone analysis was effective for both Annie and Bobby because they were in a particular phase of their analysis. The work on the telephone represented a transition from a more preoedipal position towards one in which they were able to relate to me as a separate person in my own right and consequently view themselves as initiators of their own experience (Winnicott, 1953).
The telephone analysis worked because of their special history with me. Both Annie and Bobby had a strong commitment to their analysis and had felt that they had benefited considerably from our work prior to leaving. In fact, without the analysis, neither one believed that they would have felt secure enough to have moved forward with their life goals.
Leaving represented progress, not defeat to both of them. But in each case it also stirred up tremendous depressive anxiety. Our work on the telephone seemed to serve as an adaptive defense against their separation anxiety. In addition, because of the nature of telephone communication in general, intrinsically it offers the experience of being somewhere between fantasy and reality, which Winnicott (1953) believes is at the very basis of initiation of experience.
Through our work on the telephone each analysand made an important transition into a more mature position. In much the same way that an infant eventually decathects from his or her transitional object, as I became more meaningful to both of my analysands as a separate person, the telephone no longer served its original purpose. Each analysand began to want a more complete experience. Annie is in the process of terminating and eventually will find another analyst in the city where she lives. Bobby, on the other, looks forward to resuming his analysis in my office, person to person.
Though my experience is very limited, I hypothesize that telephone analysis may work more most effectively with analysands in a transitional phase. While, obviously, there will always be exceptions, I suspect that analysands whose sense of self is too undeveloped might find the experience too depriving. While analysands whose sense of self is highly developed might discover that something meaningful is missing. Telephone work may be an acceptable accommodation due to life's exigencies in the short run, but it may not be a long term solution.
Conclusion
We are living in a changing and highly mobile culture. Often if our analytic work is helping, patients will have options available to them that they had never dreamed possible. Under ordinary circumstances there often is sufficient time to terminate with a patient. But in the cases described above that was neither possible, nor perhaps desirable. Having telephone analysis as a viable treatment alternative allowed each patient to have a more adaptive and meaningful transition into a new phase of their life while being able to continue their analysis.
The cases above raise many questions about telephone analysis. In the most fundamental way it pushes our notion of intimacy. When the psychoanalytic process is channeled through only the verbal realm, it challenges us to rethink our familiar analytic concepts and to reformulate our technique.
Obviously, one paper cannot address the many issues needed to be raised. However, there is a font of information out there. Up until now those of us who do telephone work having been doing so in isolation without the benefit of discourse from our colleagues. Hopefully, by bringing this topic out into the open, we will be able to better assess the implications of this type of work.

References

Bacal, H. A. and Thomson, P. G. (in press). The psychoanalyst's self-object needs and the effect of their frustration on the treatment: a new view of countertransference. Progress in Self-Psychology, Hillsdale, New Jersey, The Analytic Press.

Brockropp, G. W. (1976), Crisis intervention and counseling by telephone, (2nd edition), Springfield, Illinois, Charles C. Thomas Publisher.

Freud, S. (1912). Recommendations for Physicians on the Psycho- Analytic Method of Technique. Standard Edition (12).

(1913). Further recommendation in technique of psychoanalysis-on beginning treatment. Standard Edition (12).

Grumet, G. W. (1979). Telephone therapy: a review and case report. American Journal of Orthopsychiatry. 49 (4). 474-584.

Lindon, J. A. (1988). Psychoanalysis by telephone. Bulletin of the Menniger, 52, 521-528.

Renik, O. (1993). Analytic interaction: conceptualizing technique in light of the analyst's irreducible subjectivity. Psychoanalytic Quarterly, 62, 553-571.

Renik, O. (1994). Countertransference Enactment and the Psychoanalytic Process in M. Horowitz, , O. Kernberg, and E. Weinshel (Eds.) Psychic Structure and Psychic Change, Madison, CT. International Universities Press. 135-158.

Robertiello, R. C. (1972-1973). Telephone sessions. Psychoanalytic Review, 59, 633-634.

Saul, L.J. (1954). A note on the telephone as a technical aid. Psychoanalytic Quarterly, 20, 287-290.

Winnicott, D.W. (1953). Transitional Objects and Transitional Phenomena. International Journal of Psycho-Analysis. 34.

Zalusky, S. (1995). Unpublished doctoral thesis. Analyzability from at intersubjective perspective.

(1988). Unpublished doctoral thesis. Social responsibility and empathy in adolescent volunteers.

Notes

1 Though I did not do a formal survey, I presented a draft of this paper to an informal group at my institute. On a rainy evening with only a week's notice twenty analysts showed up to discuss the topic. Almost everyone at the meeting related their own personal experience conducting an intensive analytic treatment over the telephone. Others who have done analytic work on the telephone but were unable to attend called for a copy of the paper. My experience has been the more one talks about telephone analysis, the more one hears about its practice.

2 It is in this passage that Freud uses the metaphor of the telephone. Freud states, "He [the analyst] must adjust himself to the patient as a telephone receiver is adjusted to the transmitting microphone."