British Journal of Psychotherapy 33, 1 (2017) 63–76 doi: 10.1111/bjp.

12267

Clinical Practice and Technological Change

ADVANCING TELECOMMUNICATION
T E C H N O L O G Y A N D I T S IM P A C T O N
P S Y C H O T H E R A PY IN P R I V A T E P R A C T I C E

CHRISTOPHER VINCENT, MARY BARNETT,

LOUISA KILLPACK, AMITA SEHGAL and PENNI SWINDEN
This paper is a report on an informal study by a small group of
psychotherapists interested in exploring the impact of recent technological
innovations on their work as independent clinicians in private practice.
The range of technologies studied included websites, email, mobile
phones, and internet-based banking services for payment and receipt of
fees. Some of the group had experience of using internet-based video
software (or Voice Over Internet Protocol/VOIP software) for providing
therapy and/or establishing supervisory and training links. The study
found that these technologies have had both positive and negative impacts
on professional practice and, in particular, records how practitioners have
managed these changes within their clinical practice. The study notes the
lack of professional training about these matters and highlights some of
the issues that need to be addressed in redressing this situation.

KEY WORDS: ONLINE THERAPY, ONLINE COUNSELLING, INTERNET

THERAPY, PSYCHOTHERAPY, TECHNOLOGY, THERAPEUTIC FRAME,
COMMUNICATION, TELEANALYSIS

INTRODUCTION
The evolution and rapid development of telecommunications technology has trans-
formed the way we communicate and transmit information. Nowadays mobile tele-
phones are commonly used for conversing in person or through voicemail or short
message service messages (SMS, commonly known as ‘text’ messages), watching
television and surfing the internet. Advances in internet technology have not just
made information more available to people, people have been made more available to
each other too, requiring us to consider the possibility that these developments have
brought about unprecedented changes in the human condition (Fonagy, 2014). The
internet now offers us new ways of managing relationships as well as managing infor-
mation. The widespread use of the mobile telephone coupled with increasingly
sophisticated methods of electronic communication like email, text messages, social

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media messaging and image sharing, powerfully impacts upon the way we conduct
our daily lives. What is the impact on the psychotherapy profession of this technolog-
ical revolution? Can we harness its power, be alert to its pitfalls and dangers, and
think in an open-minded, analytic way about its impact on practice?
Many of the technological advances examined in this study have become inte-
grated within private clinical practice almost without conscious awareness. For exam-
ple, the steady replacement of letter writing by the use of email has had a major
impact on the speed of communication between clients and therapists with the conse-
quence that there is often an erosion of the boundaries between therapists’ work and
private hours. The participants in our study reported that they had not given adequate
consideration to how the ease and speed with which emails are sent might argue for
clarifying the working hours within which their clients might expect replies. This
challenge to practice was one example of the ways that technology has crept up on
therapeutic practice in recent times (and is likely to go on doing so) and it was, there-
fore, thought timely to take a snapshot of how therapists were managing the impact of
these innovations.
Alongside developments which have replaced former methods of communication –
such as email replacing letters, mobile phones replacing landlines and, to some extent,
internet-based banking services replacing the use of cheques – there are those technolo-
gies which have added new opportunities to the ways therapists might communicate
with clients and colleagues. These technologies include websites, social media (e.g.
Facebook and Twitter), and Voice Over Internet Protocol (VOIP) software which allow
face-to-face contact via the internet. Therapists can exercise a greater degree of choice
in whether and how they integrate these new ways of communicating into their profes-
sional lives. Study group participants made different choices about utilizing these new
technologies, some of the reasons for which are discussed in the detail of this report.
In the first six months of 2015 a small group of five psychotherapists became inter-
ested in taking stock and benchmarking how these new technologies have impacted on
their practice, aware that with the current rate of technological innovation, their find-
ings might be out of date by the time the results were published. This project was an
informal initiative among colleagues who had established professional links with each
other. The study was self-funded and its methods and ethical framework reflected the
realities of all the participants working in private practice. The ethical safeguards built
into this work drew on the codes of practice of each participant’s professional body.
A questionnaire (available on request from the corresponding author) was com-
pleted by each member of the group as well as by two experienced colleagues exter-
nal to the study. The feedback from the participants’ questionnaires drew attention
to the ways that conventional ideas about the therapeutic frame have been chal-
lenged, and it became apparent that many of these challenges have been managed in
isolated ways. The account that follows describes how their day-to-day practices
have been affected in recent years by these developments. There is little evidence
of participants asking for or being offered continuing professional development
(CPD) training on these matters. This suggests that, for the future, there is a learning
gap to be filled.

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METHOD

Participants
Seven senior and experienced psychoanalytic psychotherapists, five female and two
male, were recruited to fill in the questionnaire. The mean average of post-
qualification experience was 22 years. The age distribution was as follows: two male
and two female clinicians were in the 61–70 year age group; one female clinician was
in the 51–60 year band; one female clinician was in the 41–50 year band. All of the
group are couple therapists in addition to working with individual clients.
We suspect that the seniority and experience of the respondents had a strong bear-
ing on the results. Therapeutic practice is shaped and moulded by basic training
which for most of this group took place in the pre-internet age. In discussion we
acknowledged that the older members of the group had a more cautious and question-
ing attitude to taking on new ways of working, especially when these challenged
long-established practices. These older ‘digital immigrants’ readily acknowledged
their hesitancy and anxiety in tangling with complex new technologies which they
suspected would not be the experience of their younger colleagues who, having
grown up with these technologies, have the confidence of ‘digital natives’ (Prensky,
2001; Palfrey & Gasser, 2008).

Design
The range of technologies selected for evaluation in our study reflected the practices
of our group members. None of the participants employed social media in their pro-
fessional lives, although Balick (2016) recognized that some psychotherapists do.
One therapist briefly had a Facebook page for her private practice which she soon
took down, feeling uncomfortable at the degree to which she felt exposed by it. All
participants had varying degrees of involvement and levels of interest in the use of
websites and VOIP software.
The questionnaire evaluated the experience of having a dedicated practitioner
website and of being listed on organizational websites; the use of email in commu-
nicating with clients (ranging from point of first contact to scheduling consultations,
maintaining contact between sessions to delivering invoices); the use of mobile tel-
ephones in conducting some of these functions; delivering psychotherapy using
VOIP software; and finally, the employment of online banking services for invoice
payments.
The questionnaire sought to assess how these technologies operated in clinical
practice, and included the process of making referrals, providing supervision and con-
ducting training events. The study did not set out to give an in-depth examination of
any one technology but, instead, to take a broad overview of an array of technologies
and to record their major effects on the clinical practices of a defined group of psy-
chotherapists practicing at a particular point in time.

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66 Christopher Vincent et al.
Procedure and Method of Analysis
The findings from this study were generated in an iterative way. The seven completed
questionnaires were distributed among the five members of the group, each of whom
took responsibility for analysing subsections of the questionnaire data and writing up
summaries of emerging themes (Braun & Clarke, 2006). Their written summaries
were then discussed in seven group meetings spread across a period of 10 months.
From these discussions successive drafts of this report emerged, each one worked on
and revised by the group members.
The authors of the study were geographically spread out so that their monthly
meetings were conducted online using group videoconferencing software, VSee.
Communication between meetings was conducted using mobile telephones and
email.
There are now available for private and professional use a range of software pro-
grammes for individual and group videoconferencing (Weitz, 2014). We chose VSee
as it is compliant with the Health Insurance Portability and Accountability Act
(HIPAA), a piece of American legislation, which sets minimum standards for protect-
ing the confidentiality of electronic health information (http://www.vsee.com/blog).

RESULTS

Websites
Five of the seven study group members were included in at least one organizational
website, while two members had set up their own. The decision to do this was partly
financially driven as inclusion in organizational websites is generally more economi-
cal than setting up one’s own. Websites can be expensive to build and require regular
investment of time and money to maintain and update. Additionally, it was felt diffi-
cult to turn down the invitation to join a group website listing colleagues (who wants
to be an outsider?), and it was thought that being part of a collective listing felt less
exposing and, hence, safer than having one’s own dedicated site.
Opinions about listing and describing clinical services offered on websites were
mixed. Concerns were expressed about giving enough information so that clients can
be appropriately informed before embarking upon therapy (for example, location,
fees, time commitment, therapeutic orientation), but not creating unrealistic expecta-
tions by providing a surfeit of information. Moreover, an important aspect of working
psychoanalytically involves the therapist limiting disclosure to his or her professional
standing in order to allow the client’s conscious and unconscious phantasies to
emerge and be worked with. However, as it is becoming difficult to control the
increasing amount of information about people posted on the internet, therapists are
proving less able to put a cloak of anonymity around their professional selves. Com-
menting on this phenomenon, Gabbard is quoted as stating, ‘The classical view of
psychoanalytical anonymity is dead’ (Caparrotta & Lemma, 2014, p. 16). This expo-
sure also applies to clients, when therapists, too, can easily obtain information via the

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internet about their clients. This raises important questions about whether it is appro-
priate for therapists to access data that have not been personally volunteered by cli-
ents. Putting aside the therapeutic implications of whether therapists act in this way,
there seems little doubt that prospective clients (especially younger ones) are increas-
ingly browsing websites to access therapeutic services and are using the internet to
research the backgrounds of prospective therapists (Balick, 2014).
Overall there was a general view that websites could prove helpful for clients and
colleagues at the point of referral. One of our group described a dedicated website as
a ‘virtual business card’ that referrers might use to direct clients to obtain more infor-
mation on the therapist, thus shortening the amount of time involved in phone discus-
sions. Additionally, when couple therapy is being considered, access to website
information could assist the client initiating the referral in engaging their partner in a
discussion, especially if there is some ambivalence about commitment to a first
assessment.
One disadvantage of having an online presence is that it presents the risk of
uploaded material being misconstrued. Some respondents were concerned that web-
sites might convey over-idealized expectations of what therapy might provide.
Another reported she had to work hard at the assessment interview with a client who,
having closely scrutinized her website photograph, complained she was ‘less
friendly’ than her uploaded image had conveyed.

Email
Our data found that the use of email has increased enormously over the last five years
and has replaced other forms of communication to a significant degree. Our respond-
ents attributed this monumental rise in its popularity to the ease and the speed with
which messages can be sent and received, especially when on the move; email corre-
spondence provides an audit trail of earlier discussions; emails sent and received on
password-protected machines ensure privacy and confidentiality of the exchange; a
significant advantage in communicating with couples is that emails can be sent to
more than one recipient.
However, the ease and speed with which messages can be sent has produced a cul-
ture in which there is a high expectation of receiving a similarly speedy response.
During our group discussions colleagues regularly commented on how this implicit
expectation has impacted upon their professional practice and resulted in the erosion
of professional boundaries. Colleagues described how over time their behaviour has
changed so that, in their private practices where they are unprotected by time bounda-
ries imposed by ‘going to work’, they tend to reply to work-related email messages
from clients and colleagues at all sorts of times, including weekends and evenings.
Discussion about how email is used revealed a range of different practices. Two
colleagues made explicit with their clients the hope that emails would be limited to
scheduling appointments. Another two referred to having taken up their clients’
excessive use of emails between sessions as part of the therapeutic dialogue. One col-
league working with couples made it explicit at the initial assessment that all email

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correspondence would be addressed to both partners. This practice encourages trans-
parency of communication between therapist and couple, and also takes into account
any oedipal tensions that might arise as a result of one or the other partner feeling
excluded in such discussions. It also maintains clarity about any practical arrange-
ments that may be being discussed. As well as recording our practice, we also found
that our discussions influenced our practice: two members decided that it would be
helpful in the future to be more explicit than they currently are with clients about how
and when emails would be answered.
Another concern voiced by participants in the study was about email messages
going astray either because the wrong addressee had inadvertently been selected from
an email address list, or waiting for expected emails that did not arrive, only to be dis-
covered later in the ‘Junk’ mailbox. Some concern was also expressed about what is
included in emails: participants were aware that emails leave a record which can be
accessed by third parties whether or not this is legally sanctioned.
Interestingly, participants in the study revealed they now rarely write letters in
hard copy to clients. Some, having initially resisted resorting to email communica-
tion, gradually realized that email has become an indispensable means by which
therapists and clients communicate. One respondent noted that five years ago nearly
all her initial enquiries were by telephone, in contrast to the present day where email
predominates. This development may be linked to clients having found the therapist
via websites where email addresses are provided.
Six therapists in our sample indicated they now routinely use email in establishing
initial contact with clients and, post assessment, in making arrangements for ongoing
therapy. Once regular therapy is underway, emails assist in rearranging session times
when necessary. One colleague reported that reliance on emails could mean postal
addresses, and hence an awareness of where clients live, might not be recorded.
It was interesting to note the exceptions to this upward trend in the use of emails.
Two therapists stated that they communicated with clients using the medium that
their clients use when first contacting them. Another singled out a requirement to
communicate with general practitioners by letter because doctors’ surgeries often do
not publicize email addresses. Two in our sample stated that where they had to cancel
a session and had a choice, they would prefer to communicate this by telephone. This
was particularly the case when appointments had to be cancelled at short notice and it
was felt preferable to communicate this personally, partly to ensure that the message
was received and partly to convey the importance the therapist attached to having to
cancel.

The Use of Email as Part of the Therapeutic Dialogue

All of the respondents preferred engaging face to face with their clients only using
email as part of an ongoing therapeutic dialogue when necessary. Two of the respond-
ents described situations when they had thought it necessary and helpful. In one situa-
tion the therapist continued to exchange daily emails with a client between sessions
as a way of containing his otherwise unmanageable feelings. During sessions this

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client felt debilitated by feelings of extreme shame that prevented him from talking
about certain events in his life. Between sessions this client would describe these
events in an email as a prelude to bringing this information into therapy. In the thera-
pist’s view, this use of email enabled the client to defuse the emotional charge of the
material in a creative way, a view supported by Litowich and Gundlach (1987), and
Gabbard, who observes that ‘email communication allows one to overcome shame
and other inhibiting factors that prevent direct expression of embarrassing feelings in
person’ (Gabbard, 2014, p. 43). However, our study also reported on situations where
the use of email could have the opposite effect. In one clinical example the client who
walked out of her session in an enraged state promptly sent the therapist a vitriolic
email. On returning to the next session, she seemed to have very limited awareness of
what she had felt or how angrily she had behaved after the previous session.
Both the creative and defensive uses of email, as illustrated by these two cases,
alerted us to the difficulties of being dogmatic about its value and heightened our
awareness of the importance of considering email and other technologies as holding
significance within the context of specific therapeutic situations.

Mobile Phones
All members of the study group used mobile telephones to communicate with clients
and colleagues and most of the group acknowledged that their usage had increased in
the last five years, often replacing land lines. A minority found their use of mobile
phones in clinical practice had not increased as much as their growing reliance on
emails.
Three of our group found the mobile phone to be an inexpensive means of setting
up a dedicated professional phone; all participants felt it provided an effective and
confidential means of exchanging phone and text messages with clients. This confi-
dence can be threatened in a number of ways. For example, like emails, texts can be
mistakenly sent to the wrong recipient, and there is a potential for phones to be mis-
used. One of our respondents reported that unbeknown to her one of her clients
recorded sessions on her mobile phone. In fact, the client’s use of the recording was
subsequently taken up in the therapy in a creative way but the experience is a
reminder that there is a potential for the privacy of conversations to be broken and for
recordings to be used in both perverse and creative ways.
Mobile phone use among the respondents varied. Some of the variation in use was
shaped by client preference and behaviours. For example, texting, with its conven-
ience, brevity and immediacy, was noted to be especially favoured by younger clients
who have grown up with it, and who use it to communicate as a matter of course.
Where texting was used by therapists, it was generally in reply to last minute practical
changes to session times invariably initiated by their clients.
Within our group of respondents there seemed to be a broad difference between
those who only used mobile phones for establishing or modifying the boundaries of
the therapeutic frame like making referrals, making or changing appointment times,
and those who, in addition, had used the phone to make therapeutic interventions.

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Such actions were usually made in high stress circumstances. One colleague reported
using texts when a client stormed out of a couple session and an exchange of texts
helped the client return. Another described getting drawn into texting with a high-risk
young client who really needed psychiatric help alongside her therapy, but felt unable
to access it. As a result, the therapy took on the function of crisis management. In the
daily exchange of texts the client had felt temporarily contained by the therapist’s
replies. For this disturbed woman the increasing frequency of text exchanges thought
necessary during a crisis created an unrealistic expectation that the pattern would be
maintained when the crisis had passed. When this proved not to be the case the patient
reacted by withdrawing from therapy. The therapist felt that the pressure on her to
respond to the barrage of texts was related to her anxiety about containing a very trou-
bled patient at a point of crisis, and judged that the complications that arose as a result
of the text exchanges significantly damaged the therapeutic frame, and were ulti-
mately unhelpful.
It was noted that the mobile phone’s advantage in facilitating very rapid and some-
times immediate contact with others carries with it the potential to become an intru-
sive and persecuting object. Stadter observes that when patients enter his office they
commonly turn off their smart phones and tablets, ‘This actually and symbolically
creates a space for reflection . . . uninterrupted by the intrusions of the internet, social
media and communications technology (calls, email and texting)’ (Stadter, 2013,
p. 3). In our study, this capacity of phone messaging to breach boundaries was experi-
enced by therapists often feeling that calls, like emails, had to be answered very
quickly, perhaps mimicking behaviour in their non-professional lives. The conse-
quence was a growing awareness of how over time many of the group had allowed
the boundary between work hours and personal time to break down. Few in the group
had made it explicit with their clients that calls were to be answered in working hours
only. We wondered whether this is likely to be a particular problem for therapists in
private practice who do not benefit from working in an organization where bounda-
ries about where work begins and ends are more clearly drawn.

VOIP Software
Perhaps more than any other of the technologies reviewed in this study, the use of
VOIP software in delivering therapy stirred up the strongest feelings and concerns in
study group discussions. There are now a growing number of software programmes,
generically referred to as VOIP programmes, which enable audio-visual communica-
tions between one or more participants. This practice has been challenged because it
is said to be particularly vulnerable to outside surveillance (Weitz, 2014; Churcher,
2012).
The use of VOIP software in work with clients echoed a much broader phenom-
enon that we began to become aware of as our discussions progressed. This study
showed that while levels of use were quite high – four out of seven participants in our
study reported using Skype or VSee in delivering therapy – it was acknowledged that
this practice was highly innovative and posed challenges and uncertainties, which

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were faced without training or discussion in a CPD forum. The study group discus-
sions understandably provided a much needed thinking space for us all. As our work
progressed we realized that other therapists were likely to be in a similar position. A
limited survey of members of the British Psychoanalytic Society showed that about a
third had experimented with telephone and/or VOIP analysis (Fornari-Spoto, 2011)
and yet there is reported to be a reluctance to be open about this practice (Caparrotta
& Lemma, 2014).
At the beginning of our study, six of the seven participants used video software for
linking up with colleagues while three had used the technology as a medium for deliv-
ering therapy. Encouraged by the experience of others and the discussions that cen-
tred on this way of working, another member of our group began offering therapy
over the internet as the research unfolded. Some colleagues were explicit in not want-
ing to use these technologies, having been put off by fears that the medium was not
secure from outside surveillance and by reports that the technology itself can be unre-
liable. These colleagues stated that they would only consider working in this medium
with existing clients who for any reason had to relocate.
In total, six clinical cases were referred to in our discussions, four being work with
individuals and two with couples. The most commonly cited single reason for using
such software was geographical distance preventing face-to-face contact continuing.
One colleague also described working with a couple where a video link was used
when one of the partners went through a debilitating episode of depression and leav-
ing the home was difficult. In relation to couple work, one of our group also felt that
for couples who are both working and have family responsibilities, a home-based
computer link may be the only viable means of fitting in therapy with other
commitments.
Those colleagues who had used video links as part of therapy reported significant
technical challenges which included difficulties in setting up the connection. It soon
becomes obvious that clients themselves have to take responsibility for establishing
their end of the connection. This contrasts with the conventional therapeutic setting
in which the therapist takes responsibility for shaping the physical surroundings of
the consulting room. By contrast, in VOIP-mediated therapy, the client has a central
role in deciding how their end of the connection is set up. These decisions will include
positioning the video camera, the choice of room in their house and whether the space
can be guarded against intrusions by other household members or pets. The power
balance in the therapeutic relationship is thereby altered and whether this is a helpful
or unhelpful consequence is likely to vary from case to case.
When working with couples, a choice has to be made whether partners use one
computer link or two. One computer screen requires a couple to sit either quite close
together or further apart but at a distance from the computer’s video camera. How
this decision is made has implications in the work of a dynamic and technical
nature. Some couples may value being seated close together while for conflicted
couples this may be an anathema. Sitting further from the camera can result in poor
sound quality but this may be compensated by the benefit of gaining a fuller view of
both partners.

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Once the setup has been established, further technical challenges were reported in
the questionnaires and study group discussions. These challenges fell into two broad
categories: first, the losses associated with this type of work (which one respondent
described as a loss of the ‘total situation’; Joseph, 1985) compared with working face
to face; and second, the anxieties that therapists and clients have to live with in using
this new technology.
So, for example, there was a concern that this way of work limits the therapist’s
confidence in feeling that he or she is sufficiently well attuned to the client’s emo-
tional state (Scharff, 2012) and, in parallel, can trust their counter-transference.
Loss of image definition and distortions to voice quality play into this problem.
Moreover, the abrupt beginnings and endings of sessions mean that important infor-
mation is lost about how clients enter the consulting room, talk of their journey to
therapy and then exit the room at the end of the session. Tao (2015) explores the
impact of the VOIP setting on the analytic frame in detail, discussing whether such
a connection can provide a ‘good enough’ setting for therapy. He describes how
VOIP (or ‘teleanalysis’, as he terms it), reduces the journey to therapy to just one
click of the computer mouse, making it seem more like a magic game than making a
real, serious connection. Once a computer session is started there are questions
about how we as therapists relate to the computer screen and to this ‘virtual space’
(Balick, 2014, p. 32) imagined to exist between us and our clients. There is a self-
consciousness associated with using a video camera reinforced by simultaneously
being able to see a picture of oneself on the screen as one talks. The experience of
feeling less emotionally attuned to the person at the other end of the line coupled
with the self-consciousness that comes from observing oneself can heighten the
feeling that the conversation tends towards a narcissistic or solipsistic exchange.
Balick (2014, p. 32) makes the point that in feeling less emotionally connected to
the person at the other end of the line, there is a greater opportunity for participants
in computer-linked conversations to experiment with projecting different identities.
One respondent thought that the couple he worked with using VOIP used their
screen to present an over-idealized image of themselves to themselves and to their
therapist: that of being a linked couple (they used one video camera and sat closely
intertwined on a sofa at home), which was at odds with the reality of their non-
relating. Another colleague reported that a web camera exchange involved seeing
her client in her night clothes and sitting up in bed. These presentations of self and
couple were possible because of the clients’ control of the web camera location and
use. In both cases, the therapists pondered hard on whether these presentations
helped or hindered the therapeutic task.
Anxieties stirred up by using VOIP software were often caused by the failure to
make or maintain a connection, a point underlined by Isaacs Russell (2015). Col-
leagues reported on this problem being particularly burdensome when working with
clients who could be thought of as showing patterns of insecure attachment. Both Tao
(2015) and Wallwork (2015) echo these concerns, advising caution in using VOIP
technologies with clients demonstrating more serious problems in forming and main-
taining relationships.

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VOIP and Professional Links
Participants in this study used VOIP software fairly extensively in their communica-
tions with colleagues. All seven reported using this medium for either supervising
others or being supervised themselves. It was also apparent that a range of CPD activ-
ities were delivered using this medium. Four colleagues were using it to offer training
and three had stated that they had participated in training webinars. We were also
conscious that the work reported on in this paper was made possible by meeting regu-
larly in a video-conference format.
One significant advantage of using this medium was its cost effectiveness. Travel
costs and travel time to meetings no longer need to be accounted for. Set against this
powerful advantage was the difficulty in feeling the emotional pulse of the meeting,
whether a one-to-one meeting or a larger group. There was also a recognition that par-
ticipants need to be vigilant in safeguarding the confidentiality of clinical material
but it was felt that this could be protected with adequate disguise and, where neces-
sary by encryption (for example, when encryption is used to protect the exchange of
process notes between supervisee and supervisor).

The Use of Online Banking

All the respondents in our study offer the options to both clients and supervisees of
using bankers’ automated clearing services (BACS) for payment of fees. The percent-
age of clients paying in this way varied; some therapists reported the percentage to be
as high as 100% whereas for others it was as low as 10%. One colleague noted a
decrease in the popularity of cheque payments alongside an increase in payments via
BACS and cash.
The advantages of bank transfer payments were convenience, speed and transpar-
ency of transactions which clients, overall, liked. The disadvantages were that, by
removing the payment from the consulting room, opportunities can be lost or side-
stepped to consider the meaning of paying for services; the process may become sani-
tized with a fear of therapy being devalued. Close attention to account payments is
also required, to check when invoices have been paid, and this can cause problems
when there is no identifying reference on the invoice or when partners in a couple
therapy take turns in paying.

CONCLUSION
This study reports on developments in clinical practice brought about by technologi-
cal change. Most of the developments discussed in this report have become accepted
into practice in two ways. First, there were those developments that had crept up and
become part of day-to-day practice almost without conscious awareness. The use of
email and mobile phones seemed to fall within this category. But, second, there were
those technological innovations where psychotherapists have exercised choice about
whether and how to integrate them within their professional working lives. Social
media, websites, VOIP software and payments by bank transfer fell within this group.

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74 Christopher Vincent et al.
When thinking about these technologies it became apparent that they all comprise
elements of the therapeutic frames within which therapy takes place and that the
changes they have brought about raise questions in a number of important areas.
First, they have impacted on therapeutic boundaries. All the technologies we dis-
cussed have made communication easier, faster and less costly than the methods they
have replaced. We have tried to spell out how we as practitioners experienced the
advantages and disadvantages of faster communication. We were all surprised by the
incremental manner in which some of us had allowed this acceleration to blur the
boundaries between work and private hours in unhelpful ways, raising the possibility
that, at assessment meetings, expectations about response times to emails and texts
need to be clarified.
Second, changes to the therapeutic frame influence what happens within that
frame. We have considered some of the advantages and disadvantages of using email,
mobile phones and VOIP software as part of ongoing therapy. In exploring these pos-
sibilities we were struck by the inhibitions that exist to openly discussing these inter-
ventions, perhaps because they challenge long-held conventions about how as
therapists we ought to practice. These inhibitions need to be overcome so that we can
explore the dynamic issues that working with these technologies present.
Third, we are aware that important ethical and legal questions are raised by the use
of these technologies (Wallwork, 2015). Should practitioners be formally trained in
the use of new techniques like VOIP software? Do professional indemnity insurance
policies cover psychotherapeutic work using video software, particularly if this work
crosses international boundaries? Should therapists be registered with the Office of
the Information Commissioner as data controllers under the UK Data Protection Act
(Weitz, 2014)? These are just a few of the questions raised by our study. As far as we
could tell, the professional bodies of which respondents were members at the time of
the study (January to June 2015) had not issued any practice guidelines or advice in
this area.
This project was set up by a group of therapists who became aware that their prac-
tice was changing under the sway of technical innovations and considered that these
changes needed to be benchmarked and discussed. They recognized the paradox that
while technology was altering the nature of the therapeutic frames within which they
practiced, there was little written about how different technologies interact with one
another to shape the overall psychological containment they are able to offer their cli-
ents. They thought such a deficit warranted taking an overview of their practices,
aware that such an approach could be criticized on a number of grounds. They recog-
nize that by taking a broad overview the analysis could be considered superficial in
that each of the technologies mentioned could have been examined at greater depth.
They also concede that the analysis is essentially descriptive and does not explore the
dynamic significance of these technologies within detailed clinical situations. In tak-
ing this extensive and descriptive perspective we hope that we have laid some
groundwork for more in-depth research.
Methodologically the study can be challenged for utilizing VOIP software as
part of the research method when also claiming to evaluate its effectiveness. In

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 Telecommunication Technology and Psychotherapy 75
fact the research group felt that communicating with one another via VSee brought
to life many of the dilemmas which the study was attempting to describe and
understand.
The study attempts to describe how a particular group of therapists who undertake
couple and individual psychotherapy in private practice are thinking about the impli-
cations for them of recent technological changes. The hope is that by describing their
own experiences, it will help others to reflect on their practices and to facilitate a
much needed professional dialogue.

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76 Christopher Vincent et al.
CHRISTOPHER VINCENT is a psychoanalytic couple psychotherapist registered with the
British Psychoanalytic Council (through the Tavistock Institute of Medical Psychology). He is
a visiting lecturer at Tavistock Relationships, and maintains a private practice in Hayling
Island, Hampshire. He has a special interest in the interface between psychosocial research
methods and psychoanalysis, particularly as this applies to the support and treatment of couples
where one partner has a chronic illness. Address for correspondence: 60 North Shore Road,
Hayling Island, PO11 0HN [vincents11@ntlworld.com]

MARY BARNETT is an individual and couple psychotherapist registered with the British Psy-
choanalytic Council (through the Tavistock Institute of Medical Psychology) and maintains a
private practice in Brighton. She has worked as a psychotherapist in the NHS and the Univer-
sity of Sussex psychological services. She has a special interest in psychotherapy research and
in the application of an attachment perspective to clinical work and organizational functioning.

LOUISA KILLPACK is a psychoanalytic psychotherapist registered with the United Kingdom

Council for Psychotherapy (through her membership of the Association of Group and Individ-
ual Psychotherapy) and maintains a private practice on the Isle of Wight. She has worked as a
psychotherapist in the NHS and has special interest in working with borderline personality dis-
order and patients with chronic physical pain.

AMITA SEHGAL is a psychoanalytic couple psychotherapist registered with the British Psy-
choanalytic Council (through the Tavistock Institute of Medical Psychology) and a Collabora-
tive Practitioner with Resolution (formerly the Solicitors Family Law Association). She is a
Visiting Lecturer and Clinician at Tavistock Relationships, and maintains a private practice in
Central London. She has a special interest in the place of neurobiology in contemporary attach-
ment perspectives as applied to couple psychotherapy and in the psychological processes of
separation and divorce that inform her commitment to resolving family disputes in a non-
confrontational, out of court setting.

PENNI SWINDEN is a psychoanalytic psychotherapist registered with the British Psychoana-

lytic Council (through the Psychotherapy Foundation for her work with individuals and the
Tavistock Society of Psychotherapist for her work with couples). She is a supervisor and a vis-
iting lecturer at the Tavistock Centre in London and maintains a private practice in Hampshire
and London. She has a teaching background, has worked extensively in the NHS and has
headed the clinical service of a WPF counselling agency.

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British Journal of Psychotherapy 33, 1 (2017) 63–76
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