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Many therapists have not gone back to in-person sessions even though most Covid restrictions have been lifted. Before March 2020 I was firmly convinced that telephone sessions were better than skipping sessions, but not as valuable as in-person sessions. I only agreed to telephone sessions when patients went on business trips or some other compelling reason made them unable to come in person. But beginning in March 2020 my practice transformed to all phone (or in a few cases, video) sessions. After two years of living in my "weekend" house in Connecticut, I sold my office in New York and accepted the fact that my practice was now going to be entirely by telephone. I use video calls for new patients (for a determined period) and for couples, but telephone sessions for everyone else.
Since my "conversion" I have thought a lot about the pros and cons of telephone vs. in-person treatment. In the newest volume of The Psychoanalytic Review, Carl Jacobs writes, “telephony is so much preferable to video. Since the time of its origin, psychoanalysis has been based predominantly on listening: The use of the couch is more easily replicated by telephone.” Jacobs experienced in-person and telephone sessions in his own analysis and writes about the intimacy and mutuality engendered by hearing his analyst’s breath. (The Psychoanalytic Review, Volume 111, Number 1, March 2024.)
I agree that for some patients speaking on the phone makes it easier to talk about difficult subjects and it may feel more intimate than video or even in-person treatment. However, phone sessions and video sessions make it impossible for the analyst to recognize non-verbal enactments: John slams the door each time he enters my office; Hal has body odor; Janet brings coffee to her session and spills it on the carpet in my waiting room; Barbara puts her feet up when she sits on my couch without taking off her shoes. In all these cases, analysis of the meaning of the behavior would lead to fruitful discussions of their unconscious meaning.
Another problem with telephone sessions is that it is much harder to keep the frame intact. The therapist does not know whether the patient is sitting in his living room, on a park bench, or in his car. One patient was walking home during our session and the differences in her breathing were not due to her emotions as much as the traffic on the street. The therapist does not know if the patient is fully dressed or whether someone else is within earshot of the session. It is difficult to set the same boundaries on the phone as one would be able to maintain in an office.
It's difficult to come to a one-size-fits-all conclusion about telephone psychotherapy. For some patients, the telephone encourages intimacy, while for others it creates distance; for some patients it removes the distractions that might be present in an office, while for others it introduces the possibility of a range of distractions. In the end, each therapist and each patient have to decide what works best for them.
