The Long, Tangled History of Teletherapy – The Nation
June 11, 2022
In 1991, Kenneth Colby, a psychiatrist at UCLA, released a software program that he hoped would relieve the burden on the nation’s overloaded psychiatric system. Overcoming Depression promised to make patients “experts in their own depression” through a program they could run on their new personal computers. It was a promising time for an initiative that aimed to cross-fertilize the desktop computing craze and the early-’90s rise in diagnoses of depression—encompassing 25 percent of the nation’s adults, according to the National Institute of Mental Health (NIMH), a number that Colby considered an underestimate.
But for all its promise, Overcoming Depression landed with a thud, another failed dream of the 1990s. The challenge of moving from a prototype to a functioning software system that could plausibly replace a human clinician proved too daunting for the NIMH, which cut the project’s funding after only a few years. Griping at what he considered the institute’s conservative vision, Colby remarked, “I think the ultimate funding will come from the private sector when it realizes how much money can be made from conversing computers.”
Colby was right. In 2020, mental health start-ups garnered $1.5 billion in investments, with companies like Cerebral leading the pack on a wave of VC cash. Many of these new companies specialize in fast-tracking prescriptions for controlled substances like amphetamines, capitalizing on the Covid-era relaxation of in-person prescribing rules. The legal gray areas surrounding these apps and how they should be regulated is a predictable result of the way every facet of our lives was clambering shambolically online during lockdown. But data about the extent to which these new forms of digitized psychiatry have changed the field—much less whether or not they work—remains alarmingly scant. Like QR codes, teletherapy and Web psychiatric consultations now seem less like a temporary emergency measure and more like part of an indefinite new normal. Sure, the much-touted increased access to psychiatric care comes laden with questions about treatment standards—but in the tyranny of the permanent ad hoc, who has the energy to ask whether the thing to which there are no alternatives is any good?
Hannah Zeavin’s The Distance Cure takes on the question of telepsychiatry’s therapeutic validity by examining the many ways that psychiatry and psychoanalysis have historically been practiced without an in-person session—from Sigmund Freud’s analyses conducted via written correspondence to call-in radio shows and suicide hotlines. As a history that looks into present trends, the book aims not only to contextualize teletherapy by assembling a larger genealogy of psychotherapy at a distance but to use it as a way into the problem that defined the quarantines: how to transact intimacy at a distance.
Psychotherapy that happens without both parties in the same room is not just a niche within the larger genre of “communication,” Zeavin argues. Instead, distance therapy reveals something that is true of human communication in general: that all intimacy relies on a fantasy of togetherness, even when the parties are physically present with each other. There is, she asserts, no way to be “really” together with someone else that doesn’t rely on a third thing traversing the space between “me” and “you.” This third thing, per Zeavin, is “media,” a vertiginously broad concept encompassing any means of communication, from a chat over lunch to a transatlantic telecom line. Rather than understanding teletherapy as “more distanced” than in-person therapy, then, Zeavin contends that different types of media facilitate different types of fantasies of togetherness that are, in the end, variations of the same psychic process. Whether we are FaceTiming or writing letters or in the room together, no experience of intimacy is more “real” than any other—they are just mediated differently.
To understand the stakes of what Zeavin is doing here, you have to understand two things about the small but influential academic field of media studies. The first is that media theorists are always talking about “affordances,” by which they mean how any type of media facilitates some aspects of communication but not others. Because it was integrated with e-mail, for example, Gchat made it easy to keep chats running all day at a desk job in a way that AOL Instant Messenger hadn’t, which in turn shaped how people communicated with each other and the sorts of things they said when they did. This insight is what the founder of the field, Marshall McLuhan, meant with his famous line “The medium is the message”: The effects of a message are bound up with its mediation through a channel’s “affordances.”
The second is that, while drawing on this foundational approach, Zeavin is pushing hard against the boomer orthodoxy of an older generation of powerful media scholars, most notably the MIT endowed chair Sherry Turkle, whose influential account of the rise of digital communication has circulated widely outside the academy in crossover hits like Life on the Screen and Reclaiming Conversation. Although Zeavin names no names, the arguments that Turkle advances in these books are exactly the kinds of critique that Zeavin wants us to question. Turkle holds that the digital age replaced human in-person conversations with talking to and through machines; this change was bad because it damaged something essential about human relations. Zeavin begins by asking whether this is really true. For her, toggling from in-person to digital communication does not trigger a change in intimacy at its most basic structural level. Regardless of the medium, all human communication relies on fantasizing proximity across separation, our relations mediated by “materiality” (another concept that, by the end of the book, seems slightly winded from all the lifting), whether in the form of our bodies or writing or digital instant messages.
For many of us who logged on in our teens, Zeavin’s arguments clock as bracingly reasonable, another warranted riposte by millennials against their elders’ panicked theorizing about those damn kids and their damn phones. If all human proximity is inherently mediated, Zeavin asserts, then we should stop evaluating the validity of any particular intimacy as somehow equivalent to its degree of physical presence. Yet, to the extent that The Distance Cure effectively makes the case that “real presence” is the wrong metric for therapeutic legitimacy, it opens up questions about what criteria should take its place. How are we supposed to judge whether any given type of mediated intimacy is the kind we want when it comes to psychiatric care?
In a moment in which disaster capitalism has pounced on a gaping social crisis—reframing it as a “crisis of mental health” ripe for profiteering by VC-backed telepsychiatry and tech start-ups—any serious answer to this question cannot begin with “All things being equal….” Unfortunately, and as usual, all things are not being equal. As you read this, telepsychiatry is staking out an enormous growth market premised on squeezing the gig-working medical provider for all she’s worth. If there is nothing inherently bad about psychiatric care at a distance, then figuring out whether and in what way it could be good requires that we specify the historical and political conditions in which it’s happening: In what context? For whom and by whom? And why?
Zeavin approaches these questions over five chapters, each devoted to a different method of distanced therapy, beginning with a study of two cases that Freud conducted through the mail: his own self-analysis and the case of Little Hans. Starting in 1897, Freud attempted to turn his method on himself in a process that he recounted in a series of letters to his colleague Wilhelm Fliess. Most scholars of psychoanalysis have taken these letters to be a straightforward account of Freud’s self-analysis, but Zeavin argues that, more than simply chronicling a process he’d already conducted elsewhere, the correspondence itself was the way that the analysis was mediated. Psychoanalysis has sometimes indulged in pretending that the in-person encounter facilitates a kind of telepathy, but Zeavin underlines that there has always been a distorting medium involved, even with both parties in the room. As Freud developed his method, she notes, he repeatedly invoked metaphors of mediation to describe the processes of “the talking cure”: Dreams are like mail carried by a censored postal system, memory is like a mystic writing pad, and analytic listening is like a telephone call.
If there is some analytic slippage here between metaphor and method—after all, what do the metaphors prove?—Zeavin hits on more definitive evidence with the case of Little Hans, an analysis conducted entirely through letters between Freud and the patient’s father. When Hans was 5 years old, he suddenly developed a phobia toward horses, and the boy’s father turned to his close friend Freud for help. The famous clinical peculiarities of the resulting case gave Freud a critical test zone for his then-budding theories on childhood sexuality. Freud met Hans only once, after which the child’s father would relay written reports about Hans’s behavior to Freud, who would respond with advice and lines of questioning that the father would then implement.
Taken together, Zeavin argues, Freud’s self-analysis and his analysis of Little Hans demonstrate that therapy at a distance is not a deviation from the “original” psychotherapeutic technique but existed at the very outset of the talking cure. If this is an implicit argument from authority—that is, that distanced therapy must be at least as legitimate as Freud’s cases of in-person treatment if he did both—it is all the same an effective strike against arguments that distance necessarily degrades psychotherapy’s original form. But although Zeavin’s argument—that the intimacy created by letters, on the one hand, and by in-person therapy, on the other, were “not identical, but [could] be used to achieve similar aims”—works well for Freud’s study of himself, it’s harder to defend when it comes to Little Hans. As Zeavin herself notes, scholarly critics have often pointed out the questionable legitimacy of the Little Hans analysis. A rigorous 1963 paper combs through the correspondence archive, in which Hans’s father transcribed his conversations with his son, to show the parent quite literally feeding the child lines (“And then you wanted Mommy to drop baby sister in the bath to kill her, didn’t you? So you could be alone with Mommy, isn’t that right?”), to which Hans would distractedly agree. This questionable “data” was then presented to a pleased Freud via letter as proof of the Viennese doctor’s theories. Read skeptically, the case makes it hard to avoid inflecting Zeavin’s thesis with further questions: All therapy is mediated, sure, but then doesn’t the Little Hans case imply that some forms of mediation are less effective than others? And if so, how do we decide whether a particular form of mediation is good or bad?
These questions recur through the rest of The Distance Cure, as Zeavin presents studies of various therapies at a distance, many of them empirically rich enough to show the multiple and often conflicting political projects a given type of media has been used to pursue. The medium is not always the message so straightforwardly, it would seem, and Zeavin gives one instance after another of psychotherapeutic media used by groups with varying or even conflicting goals. In the chapter on radio therapy, for instance, she describes the English psychoanalyst Donald Winnicott’s radio hour for mothers who were turned into single parents by World War II, an effort to get psychoanalytic advice to the masses who couldn’t afford expensive shrinks. Winnicott’s fireside-chat style of parenting advice contrasts with both left-wing programs like The Voice of Fighting Algeria (which unified a movement resisting violent French colonial rule) and right-wing programs for the 1980s moral majority, such as Dr. Laura Schlessinger’s call-in show (which preached “family values” as the cure for distraught advice seekers). The strength of the chapter lies in its dazzling discussion of a wide range of radio therapy programs, and it offers a tour de force of a particular kind of scholarly analysis: one that coaxes similarities out of variations in the historical wild in order to illustrate unifying theoretical concepts. Still, it’s not always easy—at least not if we’re going by the book’s descriptions of what was actually said on the shows or their political milieu—to deduce which types of programs the author would endorse, and why.
Similarly, the fascinating chapter on suicide hotlines leaves the reader with no clear or definitive answers about what Zeavin makes of the political capacities of the medium. Here we encounter the gay Anglican priest Bernard Mayes, who created one of the nation’s first suicide hotlines in the United States in 1961 to help curb San Francisco’s staggering suicide rate. At a time when psychiatry still held that homosexuality was a mental disease, the hotline became a de facto ministry to the city’s queer community. (That’s good, presumably.) Yet the hotline’s Protestant roots made it equally viable as a recruiting tool for organizations like the burgeoning megachurch-cum-self-help empires, often by using scads of hastily trained volunteers to man the phone lines and scoop desperate callers into an organization’s waiting arms. (That doesn’t sound so good.) Given the distressed state of the nation’s mental health capacities following the bureaucratic debacle of deinstitutionalization, these initiatives can be seen as understandable attempts to close the gaps in care. But as Zeavin describes the volunteer-based model of the hotline, with people on the brink of killing themselves calling to make contact with unpaid volunteer counselors, the reader may wonder whether these hotlines really provide a model we’d want to replicate, at least given any other options.
Of course, Zeavin’s extensive writing in public-facing outlets hardly leaves room for suspecting her of secretly sympathizing with Laura Schlessinger or evangelical megachurches—far from it. The point of a historical analysis is not to dole out easy parables, and ambiguity can be productive. (Ask any psychoanalyst.) But if we are going to create a better, more just psychiatric system, we are going to need answers. To mention only one major problem that crops up in almost every case study Zeavin examines, how do we deal with the trade-off between access to psychiatric care and the quality of that care? If you turn the dial toward relaxing the professional accreditation requirements for providers, you get more widely available care, often provided by people who are not part of a racist and classist medical apparatus, and who might even be from the same minority community as the patients. But you also create opportunities for a host of shady grifts, each promising help in the service of making a buck or pushing an organization’s agenda. Turn the dial the other way, toward a tighter regulation of care, and not only does care become harder to find, but the psychiatric profession can start looking like the shadiest grift of all, slinging dubious medications into a social crisis defined by widespread anxiety and despair.
These are hard problems. If the left is going to come up with solutions, we will need historical studies that dig into the weeds of how these concerns played out in the past and that have an opinion on them. These kinds of projects will have to unfold in the space that The Distance Cure opens up for analysis—outside of a moral hierarchy of media adjudicated by “real presence”—and with eyes peeled to the rapacious ingenuity of the capitalist medical system to gouge profits out of a political crisis.
While The Distance Cure’s ambit is psychotherapy at a distance in the broadest sense, Zeavin’s later chapters look directly at the present, laying out an indispensable genealogy of computerized and Internet-mediated psychotherapy. The story of the original therapeutic chatbots such as ELIZA and SHRINK is well-known to historians of psychiatry, for instance, but Zeavin dexterously foregrounds the telling details to provide a more immediately useful history for the present. In 1966, Joseph Weizenbaum, a programmer at MIT, created a program he called ELIZA, a bot that used natural language processing to converse with human users. While ELIZA was built to mimic a psychotherapist, the resemblance was incidental; far from trying to replicate a human therapist, Weizenbaum meant for ELIZA to demonstrate how little responsivity was needed to make humans feel they were having a meaningful interaction with a machine. But the people who were supposed to be testing the program seemed to be having genuinely emotional conversations with ELIZA. The experience radicalized him against the expansion of computers into human affairs, and he would later argue that the idea of a computer replacing a human therapist to provide effective psychotherapy was “perverse.”
Despite Weizenbaum’s warnings, ELIZA spawned imitators like SHRINK, which was explicitly intended to replace the scarce and expensive labor of human clinicians. SHRINK was created in the computer science department of Stanford University by Kenneth Colby (the psychiatrist behind Overcoming Depression), with the idea that the machine would rapidly process patients during hospital intake. But problems snarled the attempt to put SHRINK into use. In contrast to the delighted chatter of ELIZA, SHRINK users often raged against the machine. A representative transcript of one session reads:
person: I don’t understand. program: Do you want to understand. person: I hate you, you stupid machine. program: What don’t you like about me. person: You have no feelings. program: How do you mean. person: I mean you cannot experience what I experience because you are just a machine. program: Tell me more about such feelings. program: I am trying my best to communicate with you.
“Almost everyone who has participated in these dialogues reports that he comes to feel annoyed and frustrated by the program’s responses,” a puzzled Colby wrote.
In accounting for these differences, Zeavin argues that techniques ranging from diaries to mood-tracking apps can be thought of as facilitating “auto-intimacy,” or a process in which patients relate to themselves through a technology without another human in the loop. But not all auto-intimacy is created equal, with some forms more amenable to a bootstrapping and individualized self-help approach than others. Zeavin ties the emergence of therapeutic computer programs intended to “reprogram” patients’ thoughts and behaviors to the rise of cognitive science in the 1970s, which ousted psychoanalytic therapeutic paradigms on the strength of its compatibility with an emerging—and lucrative—computational regime.
This triumph of computerization forms the backdrop for Zeavin’s last chapter, which describes the rise of Internet-mediated therapies—from university message boards to “cyber clinics”—within the emergence of new types of online intimacy during the 1990s, all facilitated by various kinds of instant messaging. Here Zeavin finds a genre of computer-mediated intimacy that bucked the widespread expectation in the ’60s and ’70s that human therapists would be replaced by computer shrinks. What happened instead mirrored the way that more recent predictions of powerful AI and automation have been proved wrong: Instead of super-AIs, we have underpaid Mechanical Turks, and instead of computer shrinks, the ’90s saw the rise of therapeutic forms that connected people with other people through the Internet. If computers could not replace humans, online therapy could facilitate access to both providers and other patients. Instant messaging and e-mail were not simply a diluted form of speech or writing traditionally conceived, Zeavin contends; they represented their own genre of communication, what she calls online “therapeutic speech,” complete with its own ways of transacting distance and communicating presence.
The first regulatory framework for “cybertherapy” emerged in 1996 in California, then still in the first blush of the Silicon Valley boom. Care through e-mail and often spotty video chatting was envisioned by its clinician proponents as a solution to the failure of the community mental health movement. Asylums had been dismantled in favor of a community-based network model that never got the funding it needed to be more than a short-lived administrative fiasco. Throughout the 1990s and early 2000s, online therapy—often augmented by phone conversations—offered patients flexibility and a respite from the sometimes daunting intimacy of an in-person encounter, but it could be hard to gauge what these new modes meant for the quality of care. Certainly it was better than nothing, but clinicians grappled with the difficulty of inferring basic, medically relevant facts that would have been a seamless part of an office encounter, such as assessing whether the patient was maintaining basic grooming or showing up to sessions drunk. These kinds of trade-offs are still in play for teletherapists today: Seeing the patient’s living environment can be illuminating, but instant-messaging-based therapies can leave out many of the clues that therapists trained for in-person care normally use. In short, the affordances are different.
By not assuming that in-person therapy is automatically the most legitimate or authentic type of intimacy, The Distance Cure asks us to think about therapeutic mediums as offering different types of intimate interaction, not more or less of it. But while Zeavin, in a moving finale, recounts the heroic efforts of many therapists to serve patients during the pandemic, the book leaves room for questions about the quality of the care provided by teletherapy as it is currently structured by the profit motive. The mise for the present scène was set with the 2010 passage of Obamacare, which required most insurers to cover mental health. That same year, Microsoft, Google, and Samsung released smartphones to join the iPhone, which had debuted three years earlier. A deluge of newly insured patients seeking therapy swamped existing clinical capacity, creating the market conditions for venture-capital-backed teletherapy start-ups like Talkspace (founded in 2012) and Betterhelp (2013) to reorganize care models along gig-work lines.
“Help is no longer hard to find…[but] good help still may be,” Zeavin writes, noting that the study Talkspace constantly invokes to validate its model had only 57 participants and measured outcomes with a dubiously nonspecific ratings scale. And there are other reasons for concern: not just the danger that such start-ups can go belly-up and abruptly terminate patients’ care, as in the case of the now-defunct company everbliss, or the risk of privacy leaks, such as the Talkspace imbroglio that resulted in dozens of patients’ names being revealed. More fundamentally, it’s a question of the quality of care that results from a gig-work model that piles therapists with the highest possible caseload for the lowest possible fee. A March 2022 Businessweek investigation of Cerebral, a tech-darling start-up, found that prescribers, pincered between Yelp-like patient reviews and the company’s management, feel pressure to loosen their qualms around the Rx pad, while patients are forced to bounce between therapists who keep quitting, burned out by the platform’s grind.
As The Distance Cure discusses, distance therapy is often offered as a solution to the problem of accessing care. Yet analyzing these case studies by reaching for what unites them at a general level (“mass intimacy” in the case of radio programs, for instance, or “auto-intimacy” in the case of computer-mediated therapies) may come at the expense of missing the ways in which we can draw distinctions. It also hinders our ability to contemplate whether distance therapy is any more liberating than the in-person version. If anything, The Distance Cure successfully argues that therapy at a distance is not necessarily worse than therapy in person—but also that it is not necessarily better either. The take-home is that if telepsychiatry gets us out of some political problems in mental health care, it lands us squarely in the face of others.
By rejecting a false hierarchy of intimacy, The Distance Cure points away from the dead-end approaches that rank types of intimacy and human communication based on their form instead of their content. In a deftly argued coda, Zeavin asserts that the problems with one or another type of therapy are inherent not to the medium or the physical proximity involved but often to the fact that we place so much more emphasis on the setting in which therapy takes place than on its outcomes. When we attribute our frustration with contemporary life to a medium alone, we foreclose the potential to find in these media the tools for building intimacy and solidarity. In other words, we mistake the symptom for the disease. If Freud was right about anything, it’s this: That’s no way to find a cure.