Andrew Smolar, M.D.: Technology binds us, separates us


About an hour ago

In 2016, I was president of our psychoanalytic organization, when progressive colleagues aimed to train new psychoanalysts in China — which would mean providing intensive telehealth psychotherapy for them. The faculty was divided about the idea, as some favored treating patients in-person only. I was torn. I am traditional, but I also wanted to support the initiative and adapt.

So, with apprehension, I proceeded with this Chinese patient. Multiple challenges loomed: cultural and primary language differences, and our never having met in person. Yet we began to talk over the computer screen. The patient gradually told me about her family history, important relationships and the contours of her emotional life. Incrementally, we bonded, and also began to analyze the intricacies of the way she related to me. She visited one year later and we had sessions in my office; among other things, we discussed how the new setting felt. What a gift: I had been invited into a person’s inner life while she is literally a world away.

Four years later, covid-19 struck in China, and then here. Recently, distance platforms have been lifesaving. Weekly Zoom meetings with friends and family have become routine. Group exercise classes have improved our fitness. After my father-in-law died, our rabbi led a poignant Zoom-mediated service that included friends and family from afar. The service didn’t replace the usual tears, hugs and in-person stories, but it was soothing, and I can imagine adding Zoom-connected friends for future ceremonies.

I am concerned, however, that enthusiasm for remote meetings is threatening to overlook a basic human need: engagement in common physical spaces. The broadest application of distance platforms has been to education. With schools closed, various online platforms have replaced the classroom.

Outcomes of online compared with in-person courses demonstrate mixed results for students, depending on a number of variables. Typically though, expert teachers know the body language and moods of students and know when to challenge them and when to deflect them to their peers. Teachers harness the subtle group dynamics of the classroom and maximize them to enhance individual learning. Sensitive responsiveness to these details online is daunting.

Telemedicine has previously delivered care to patients who were housebound or residing in prisons or nursing homes. Now many patients have embraced it — particularly when a physical exam isn’t necessary — citing its convenience.

Some physicians feel similarly. This is understandable, given they have been traumatized by this pandemic and subjected to the erosion of the patient-doctor relationship by rushed visits and the electronic medical records. We shouldn’t exchange ease for quality, however. Reading of facial cues, nuanced back-and-forth, textured description of what ails in the physical presence of the physician — this should be the standard encounter.

During this time of practice, I have found telehealth platforms superior to the phone for individual therapy. The direct eye contact provides more information in the moment about what the pair is thinking and feeling. Yet I miss the way people greet me in my waiting room with their favorite magazine article, the way they walk into my office, the way they occupy space in the chair, the way they don their clothes, how they digest items around us — all of these characteristics are personal. The main goal for the patient is to be known uniquely, while being part of the sapiens tribe.

My experience with my therapy group, which now meets weekly on Zoom after years of jelling in my office, has also confirmed my mixed impressions. They describe an attenuation of cohesiveness and lack of access to feelings that can be intuited — without words — when they are together in-person. We’ve agreed, however, that we’ve had to make the best of the current reality.

What have these months reinforced about our humanity? That technology can temper our losses, while also obscuring our basic relational needs. That what is facile isn’t optimal. That our bodies contain information about who we are, and facilitate bonding. That intangible elements of relational intimacy transpire in-person primarily, when people can feel each other’s presence.

Sometimes intimacy transcends the screen. When covid-19 hit American shores, and when my Chinese patient learned of our PPE shortage, she mailed two boxes of masks, asking that they be shared with my medical colleagues.

What will be necessary for people to collaborate to solve global problems? That remains to be negotiated, but it will surely require some blend of technology and relating face-to-face.

Andrew Smolar, M.D., is a psychiatrist and clinical associate professor of psychiatry at Temple University School of Medicine and training and supervising analyst for the Psychoanalytic Center of Philadelphia.

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