Infant Observation

International Journal of Infant Observation and Its Applications

ISSN: 1369-8036 (Print) 1745-8943 (Online) Journal homepage: http://www.tandfonline.com/loi/riob20

Online psychoanalytic therapy – some insights

from infant observation

Xu Wang

To cite this article: Xu Wang (2015) Online psychoanalytic therapy – some insights from infant
observation, Infant Observation, 18:3, 215-227, DOI: 10.1080/13698036.2015.1116361

To link to this article: http://dx.doi.org/10.1080/13698036.2015.1116361

Published online: 13 Jan 2016.

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 Infant Observation, 2015
Vol. 18, No. 3, 215–227, http://dx.doi.org/10.1080/13698036.2015.1116361

Online psychoanalytic therapy – some

insights from infant observation
Xu Wang*
Online psychotherapy is new to therapists and patients. On the one hand,
advanced Internet technology offers great accessibility to both parties; on the
other, it also influences elements of the basic settings of psychotherapy. These
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issues may not be fully revealed in conventional psychotherapy. The author,

who works in China, uses some insights from infant observation to explore
questions about online psychoanalytic psychotherapy, such as accessibility,
some impediments to the sense of continuity of connection, the screen, part
objects, location of therapist and patient and confidentiality. The author
suggests a link between variations in good care-giving to infants where there are
no rigid rules, and the absence of such rules for online psychoanalysis and
psychoanalytic psychotherapy. He suggests that one should be sensitive,
observant and open, cautious and abstinent, in order to offer effective therapy
to clients online.
Keywords: Internet; online psychotherapy; China; infant observation;
psychotherapy setting

Introduction
Technology has had a significant impact on psychotherapy. For example, where
Freud and the early analysts made notes of sessions, the author knows of therapists
who use a voice recorder for their notes, to facilitate their work. For many years,
psychotherapists would only have met patients face to face at a specified location
for sessions. However, in the last 10 years, with the development of online tech-
nology and Internet software the requirement of ‘being in the same space’ seems to
be more fluid. More and more therapists and counsellors are using Skype, Face-
Time and other video software to see their patients, and in the author’s experience,
this is particularly true in China, which is a very big country with relatively few
psychoanalytically trained counsellors and psychotherapists. It is only through
the practice of online psychotherapy and psychoanalysis that potential issues

*Email: wangxu@tsinghua.edu.cn
© 2016 Tavistock and Portman NHS Foundation Trust
 216 X. Wang

will be fully revealed because of the differences in the setting and the experience
which are becoming evident over time.
Infant observation is one of the most important means by which mental health
professionals and others can learn about the emotional life of human beings. For
example, the impact of the specific qualities of the nurturing environment has an
effect on psychic development. The observer also becomes increasingly alert to
different feelings and emotional reactions within himself during an observation
and, often, in writing up notes or discussing the observation later. The observer’s
feelings are often taken into account in seminar discussions. There, the seminar
leader may help the observer to manage his emotional reactions, and they may
also give some indication of unconscious communication either from the baby
or from other family members during the observation.
Many therapists apply their knowledge and understanding from infant obser-
vation in seeking to understand their patients better. A question arises from this:
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can infant observation also offer insights into online psychotherapy? The author
believes that illustrations from infant observation notes can be used to illustrate
similarities and differences between online psychotherapy and the traditional
way of conducting a psychoanalytic psychotherapy session. The author will
discuss online psychotherapy and illustrate points about the potential challenges
in online psychoanalytic sessions with extracts from baby observation notes.

Types of online psychotherapy

There are Chinese counsellors who offer regular online consultations to clients
who live in different cities. Usually, these are offered once a week and short
term. Counsellor and client sit in front of their computers or other devices and
see each other’s faces on the screen. In most cases, they would also be able to
see their own image, which raises some interesting issues about self-awareness
and ‘impression management’. Some counsellors also arrange face-to-face sessions
if the client has the chance to visit the counsellor’s city. Besides online video con-
sultation, some counsellors also use online text software to work with clients.
These form the basis of online psychotherapy in China. In this paper, the
author intends to write about a more specific area that of intensive long-term psy-
choanalytic psychotherapy and analysis using online video-linked software.
Since 2005, with the organisational facilitation from China America Psycho-
analytic Alliance (CAPA), some Chinese mental health professionals have had
the opportunity to be analysed by psychoanalytically trained and qualified psycho-
analysts, clinical psychologists or licensed social workers from the USA and other
countries. In CAPA, there is an expectation that such an analysis or psychotherapy
should be long term and intensive, as a requirement of psychoanalytic training.
The Chinese patients lie down on a couch and set the camera so that the therapist
or analyst sees the face and upper body. In this way, it is not really possible for the
patients to see the therapist’s face directly, just as in traditional analysis. But, there
 Infant Observation 217

are arguments about whether one can consider this kind of psychotherapy as
analysis. Some may say that it is analysis because the patient is lying on the
couch, making free associations and having sessions at least three times per
week. Meanwhile many others argue that it is not analysis because the online
world cannot provide the same experience as that when analysand and analyst
are in the same physical space, the consulting room. It is clearly not the same
when each of them is in a different location, across the world. It is also true
that the setting cannot be safeguarded in quite the same way, although with
careful thought this might be better than could be imagined at first sight.
In the author’s view, these kinds of online psychoanalytic sessions can be
viewed as analysis, but with very particular issues to be addressed that may not
be so obvious in ‘normal’ analysis. One issue with online psychotherapy is that
the Internet has created a virtual space regardless of the actual distance and differ-
ences in time. The therapist can log into the software from her consulting room or
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office, and the patient can lie on his sofa at home; each is in their own private
setting. But what if the therapist is planning a business trip? Can she make use
of the Internet to continue the sessions? This would not happen in the conven-
tional setting. Equally, if the patient travels around frequently, would it be ben-
eficial or not to continue his therapy by use of the Internet? The use of virtual
space with the Internet raises thoughts about accessibility and impingement
which would never have arisen in the traditional setting. I shall return to these
later in the paper.

Psychoanalytic observation
From its earliest use, psychoanalysis, named by Sigmund Freud, is characterised by
its intensity and also the requirement to use the couch. For a long time, this was a
‘restriction’ to therapists and patients, as they had to be in one location consist-
ently. The transference and countertransference can be thought about more
readily in such a setting and the therapeutic relationship potentially accesses
deeper levels in both parties. The constant setting is one enabling factor for thera-
pists to reflect on the dynamics of the session and their further interpretation.
Since its development, infant observation has provided a wealth of material for
exploring the meaning of events in the early life and interaction of babies and those
which occur in analytic practice. The author believes that it can also provide
crucial understanding for the new possibilities and challenges of online psychoana-
lytic psychotherapy.

Accessibility or impingement
As mentioned earlier, the Internet offers greater accessibility to anyone located
anywhere in the world. One might think of this as a significant development in
its potential for offering analysis or psychotherapy, especially in circumstances
 218 X. Wang

such as those in China, where analysis for candidates in training could be offered
online and where a small number of psychotherapists and analysts could offer
online treatment to patients who did not live in the same city as them.
It is equally important that Chinese professionals can access support from psy-
choanalytic organisations such as CAPA because of the existence and continuing
development of Internet technology. The author suggests that this development
has a kind of link with the development of formula powdered milk and bottle-
feeding for babies who are not breast-fed. The development of powdered milk
and bottle-feeding, which is suitable for babies of different ages, is a technology
that is now fully developed and available worldwide. It is not the same as breast
milk and breast-feeding, but its formula creates the opportunity for the babies
to be physically well nourished wherever they are in the world. The teat of the
bottle has some similarities (as well as differences) to the mother’s nipple. Two
extracts from different baby observations are presented below to highlight the
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dilemmas of accessibility and cyber-interactions.

Extract from the observation of Lisa at 4 months

Lisa was 4 months old; her mother was preparing to go back to work at the time. She was
playing, in the first part of the observation, surrounded by her grandparents. During that
time, her mother was using a breast pump to express her milk. After biting her teething
ring for a while, Lisa began to suck her thumb and started to cry. Her grandparents had
not prepared her formula milk in advance, so the baby had to wait for several minutes,
crying and twisting in her grandmother’s arms. When ready, her mother said nervously
in a low voice, ‘I wish she would drink all milk, rather than drink for such a short time
and then play.’ While the grandmother held and fed the baby, she seemed to be phys-
ically very tense. Lisa’s mother was sitting at quite a distance. They both looked at Lisa
nervously. When grandfather made some noises, grandmother looked at him accusingly.
Lisa sucked, filling her mouth. After ten minutes, she slowed down and stopped sucking,
turned her head to one side, and looked elsewhere. Grandmother said, ‘Oh no, you’ve
stopped eating again. Hurry up and eat this last bit.’ She forced the teat into Lisa’s
mouth again. Lisa didn’t suck but chewed the teat, which made the milk continue to
pour into her mouth. Suddenly she frowned as if she was about to choke. Grandmother
took away the teat, Lisa swallowed a mouthful of milk and recovered. Grandmother put
the teat into her mouth again. Lisa played with it in her mouth, but suddenly her face
flushed red. This time grandmother stayed still and Lisa started coughing as she began to
choke. Mother took out her mobile phone, approached the baby to show her some pic-
tures. She said, ‘Do something else, distract her so she can eat.’ But Lisa turned her head
and grandmother used the teat to follow the baby’s mouth wherever she turned. Mother
said, ‘Don’t waste my milk’. The observer felt extremely uncomfortable at this moment.
 Infant Observation 219

Extract from the observation of Clark, at 4 weeks

At 4 weeks old, Clark is cared for by his aunt while his mother works in a market. He
becomes a little bit agitated in his aunt’s arm. The aunt tries to figure out what has made
him uneasy and changes his wet diaper. But the baby continues to scream and begins to
suck his thumb. His aunt mixes warm water with powdered formula milk and pours it
into a feeding-bottle. As soon as the teat touched his mouth, Clark sucks energetically.
He spits out the teat, for a rest, and then wanted to suck again. Although the aunt is
watching TV the whole time, she knows when the baby pauses. She waits before
putting the teat back into his mouth again. They seem to be well-coordinated. After
the feed, Clark seems satisfied, has a big hiccup and laughs looking at his aunt.

The technique of bottle-feeding shifted the whole concept of nurturing, as it gave

caregivers an alternative way to feed their babies. Such feeding can be of good
quality, as in the example of Clark, where bottle-feeding seems to be linked
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with a warm relationship between him and his aunt and it provides convenience
to both baby and caregiver while mother is at work. But when parents are too
insistent, as in the example of Lisa’s feed, it can be very uncomfortable. The
bottle can be pushed into the baby’s mouth, and the milk flows without too
much sucking, so that it can become an impingement on the baby.
Internet technology allows online psychotherapy to be offered; however, it also
presents a similar dilemma. The therapist and the patient can meet literally any-
where. They may have their main preference pre-arranged for the therapy, such
as for the patient to be lying on the sofa at home while the therapist has logged
in from her consulting room. But when the patient is travelling for business,
should they meet? The patient would not be able to have a session if he were in
conventional psychotherapy with sessions in the therapist’s consulting room.
However, with the Internet connection it is entirely possible to travel and not
to miss a session. The author wants to argue that, in the latter situation, changing
the setting of the therapy may become an impingement for the patient. For
example, one patient talking about having a session while he was away on a
business trip said, ‘It’s like a missile to me, I feel like I am the target being followed
wherever I go.’ Additionally, the therapist may feel less able to track her counter-
transference if she changes the setting by offering an online session in circum-
stances in which she is away from her consulting room. Consciously, each may
appreciate the convenience of Internet technologies, but the unconscious
dynamic should be taken seriously. One suggestion could be that the locations
of online analysis should be limited to the ‘usual’ places, just like ordinary analysis.
If the patient does have to move then there is a question for discussion in the
analysis or psychotherapy in advance of any change. This would be so that both
can think about the meaning for that particular patient.
 220 X. Wang

Going-on being
‘Being’ is an important concept in Winnicott’s theory (1960). In the author’s
view, for the baby, the first essential should be the experience of being, together
with parents or other significant caregivers. This enables him, bit by bit to discover
that he continues to be, in the absence of those figures, initially for short periods,
and later for longer. In this way, ‘being together’ is also an important therapeutic
element in the traditional therapeutic setting and enables both patient and thera-
pist to explore the impact of being together and being separate, for example, at
weekends, or when there is a planned break. This raises the question of its
quality and characteristics of online psychotherapy?

Extract from the observation of Nick, at 10 weeks

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Nick was 10 weeks old. His mother Mrs. M always took him out for the whole time of
each observation. Mrs. M explained that the baby wouldn’t sleep at home and preferred to
be taken out to sleep in the park. She thought it was because it was cooler outside. There
were other mothers with their babies who gathered together while the mothers chatted in
the park; this made the observation difficult. In one of these observations, the baby, Nick,
was held vertically, facing his mother’s back. He was not fully awake, nor prepared to
sleep. He seemed to be seeing, passively, what came, by chance, into his line of sight.
Sometimes he would scan the face of the observer, while, at other times he stared at
other things that he could see in his surroundings. Sometimes his vision seemed to
scatter into nowhere. He lacked vitality. Mrs. M was chatting with another mother for
quite a long time. During this time, Nick gradually closed his eyes and silently fell
asleep. It was minutes later that Mrs. M noticed he was asleep and she seemed surprised.
She said, ‘Oh, so you fell asleep when I wasn’t paying attention.’ She held him horizon-
tally, explaining to other mothers that this was a good position for a baby to sleep.

Extract from the observation of Peter, at 14 days

The newborn baby Peter, at 14 days old, was lying on the bed beside his father who sat
at the bedside table with his laptop. The baby was lying on his back, covered by a thick
quilt. Only his arms were exposed, pointing up towards the ceiling. His arms were
swinging slowly like two little sticks, while his hands scratched the air. The observer
had an association, ‘It is like sea actiniae (sea anemones) floating in the current’. The
baby was making some coo-cooing noise and when he made such a noise, his father
would coo back. When the baby raised his voice, his father would look at him. He
bent over to the baby several times, cooed to the baby and patted him when he made
minor crying sounds. When his father bent over him, the baby would turn his head
towards his father. After a while, Peter made louder sounds, farted, and swung his
arms faster, as if he had become uneasy. His father closed the laptop, lay next to the
baby and observed him, making cooing sounds to respond to him, while putting his
 Infant Observation 221
finger in the baby’s hand. The baby grasped his father’s finger once, and continued to
swing. The father said, ‘Let me hold you.’ He gently lifted the baby into his arms and as
the baby returned to a peaceful state, he said, ‘You like to be held, don’t you?’
In the observation of Nick, it seemed that the mother could not bear to have the
crying baby and the quiet observer in the room, so she had to take the baby to the
park, and chat with other mothers. But when she was not paying attention and lost
her connection with the baby, the baby did not seem to feel alive when he could
not feel his mother’s arms or see her eyes or face. He fell into a motionless sleep, as
if he had not started his life outside the womb.
On the contrary, in the observation of Peter, the newborn baby’s swinging
arms made the observer think about floating sea anemones. This is exactly the
natural state of a newborn baby, just out of the womb, receiving too much, sen-
sually, but at the same time losing all senses. The immense impact of the world
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fragments the experience. Newborn babies need their caregiver’s mental capabili-
ties and physical support to build an integrated sense of themselves and their
world. The father’s gaze, his responsive sounds, his physical touching, and his
holding, enabled the baby to take this in for later use, giving the baby a feeling
of living together with his caregivers which would later become part of his
going-on sense of being.
For online psychoanalysis or psychotherapy, it is challenging to offer such
experiences of ‘being together’ because of the technical limitations. The therapist
and the patient are in different locations and, in many cases in China, or between
China and another country, in different time zones with different conditions. One
may be enjoying a hot sunny day, while the other is at home, safe from the cold
rainy night at the other end of the world. Their watches may have some minutes
difference, despite adjustments for the hour, which make the starting and ending
time uncertain. If it is noisy outside the therapist’s office and she stands up to close
the windows, a patient in the same room may feel that she has closed the windows
for him. But for a patient on the other end of the Internet, he may experience that
differently, perhaps, for some patients, more like absence or abandonment. Virtual
reality makes people prone to feelings of disconnection. Technical failures, such as
Internet connection issues, echoes, network delays and image distortions, are likely
to amplify this vulnerability. These, again needs to be considered, monitored and
taken up by the therapist if not by the patient, in online psychoanalysis.

Part-object on the screen – the whole body relationship

In most online consultations, the client prefers to sit in front of the computer
screen with the camera capturing his face and transmitting the image to the coun-
sellor’s screen and vice versa. Most online software will also let the person see his
own real-time image. Network delays may create some echoes on sound, so one
can hear one’s own voice seconds later. The experience can be broken into
 222 X. Wang

pieces; face(s), duplicated sounds; and at the same time the experience is incom-
plete: the two can only see the other’s face, not body, not hand gestures, not arms
or legs. Both experiences will create anxieties, but the question might be, which is
more anxiety raising? Is it the face-only image 30 cm in front of you or the fact that
you can only know other parts of this person in imagination? Some clients prefer
to ask their counsellors to shut off the camera, while others have themselves
decided to shut off their own web camera.
When the patient lies down on the couch during online analysis, it is hard for
him/her to see the screen, while at the same time, the therapist can only see the
patient’s face and upper body. To further illustrate the importance of whole
body experience, I want to quote from the extract from the observation of Peter
at 10 months. His whole body experience with his mother and the observer is
illustrated.
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Extract from the observation of Peter, at 10 months

Peter’s mother went into the kitchen so that the baby and the observer were alone in the
living room. The stereo system was playing some nursery rhymes. The baby crawled to
the other side of the tea table, lay down, and then sat up. He only revealed his head,
peaking at the observer, and then lowering himself again. His mother came back and
said, ‘Oh you are playing peekaboo with Lee (the observer)?’ She began to play peekaboo
herself with Peter, hiding her face with a cushion. He laughed and laughed again. Then,
she held him up, put him on the table, and said, ‘Let Lee take a good look at you!’ The
baby sat on the table, looked at the observer, and waved his arms rhythmically, as if he
was dancing to the nursery rhymes. The observer thought, ‘Such a lucky baby, he feels
seen and recognized as a whole by his mother and me.’

For a baby, the whole body relationship with his/her caregivers is extremely
important. The baby is seen, heard and registered as a whole by the caregiver,
so enabling the development of the feeling of themselves as a whole. It is a won-
derful thing for them building the feelings that their body and they themselves are
full of goodness. The (mindful) bodily presence of a caregiver provides such
experience for the baby. But with online psychoanalysis, the therapist cannot actu-
ally see the patient’s whole body including the legs and feet. The therapist does not
know whether the patient is wearing shoes or not or whether he twists his toes or
tenses his legs. She does not see the kinds of hand gestures the patient is or is not
making. She cannot tell, when the patient looks upward, what he sees on the
ceiling. The last question also relates to being in the same room together. One
may say, for patients whose symptoms are somatic that perhaps an online psycho-
analysis is not good enough, unless the therapist is able to pay special attention to
issues of bodily presence or reactions. To tackle these limitations, the therapist
might need to ask more bodily related questions, such as what is the patient
doing, or is he physically tense or relaxed in addition to more traditional questions
 Infant Observation 223

that some psychotherapists ask, such as, ‘What are you thinking?’ or ‘What are you
feeling?’

Different locations, different settings, different meanings

As mentioned previously, in Nick’s case, his mother usually took him to the park
during observations. When they were at home, their main activities took place in
the bedroom; a small room, almost filled by the double bed. So the mother had to
sit on the bed with her baby while the observer sat less than half a metre away. The
mother insisted that the observer should not observe the breast-feeding. When she
fed the baby she asked the observer wait in the even smaller living room. In either
case, observing in the bedroom, or waiting in the living room, the observer felt
uneasy; he wondered if the mother intended to make him watch closely on the
one hand and to exclude him on the other hand; he had to make great efforts
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to work on his own emotional reactions. The observation seminar group and
their supervisor also worked hard to reflect on the meaning of the observer’s
experience and what was communicated. By contrast, in the observation of
Peter, after the first month, the family were content to meet the observer in
their living room. The observer began to find it much easier to remain in the
observational role and state of mind.
In the first visit, an observer might begin to try to suggest to the family, that it
would be helpful to be able to see the baby in the home setting. But in the author’s
experience, in the later months of the observation, Chinese families tend to ask the
observer to meet them in a public spaces such as parks, no matter whether they are
living in spacious or cramped apartments. While the parents are carrying their
baby or while the baby is in a stroller, the observer has to walk beside them.
Without doubt, these different locations have different psychological meanings
and impacts on all parties – the caregivers, the observers and the babies. In
many cases, it is not as if Chinese parents are using the same outdoor settings
as an extension of their indoor activities, but more as if it is a reaction to the
infant observation. Observers may get the sense from their explanations, such
as, ‘It’s cooler outside so my baby can sleep better (outside instead of in the apart-
ment),’ as in the illustration from the observation of Nick. It is also not unusual
that the parents are about to go to the supermarket at the time the observer arrives.
Chinese parents are more likely to try to do something to cope with the observing
by a third-party; this may include cultural issues. Chinese people emphasis face.
The feeling of losing face, for example feeling humiliated in front of other
people (such as an observer) is a terrible thing for Chinese people. In his key
note speech at the 4th Chinese Psychoanalytic Congress, Gerlach (2015)
suggested in a presentation, that, ‘Shame in China relates less to the conduct of
one’s private life than to the protection of social form.’ This cultural unconscious
may have a complex influence on families and observers and their interaction, and
 224 X. Wang

probably needs much further exploration. An extract from an observation may

open some windows for reflection.

Extract from the observation of Alice, at 1 year and 2 months

When the observer arrives, Alice is with her grandmother in the communal yard. Her
grandmother is chatting with other neighbours. At the same time, Alice’s mother is
approaching from another direction. Alice is happy to see her mother and raises her
arms towards her. Mother holds the baby, and the baby makes little squealing noises
as if to express her happiness. Another neighbour tries to hold her, but the baby
refuses and turns her head away. Mother, grandmother and the lady laugh, and
mother says with pride, ‘She is just being held by her mother, how can she leave
her?’ The lady’s son (who is around 10 years old) approaches them, looks at Alice cur-
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iously, talks to her and pats her. Alice smiles at the boy and raises her hands to him.
Then the boy picks up Alice and holds her. Although the holding position is not
good and Alice seems about to slip down to the ground, she seems not to mind. Her
mother takes her back immediately; then she puts Alice on the ground, takes off her
trousers and tries to help her to pee. Alice grasps her mother’s arms, tries to stand up
and cries. Mother says, ‘OK then we won’t pee.’ Then she puts her trousers back on
and holds her again, suggesting to everyone that they should take a walk. … After a
while, the boy was eating ice-cream, and he puts the ice-cream in front of Alice.
Mothers says, ‘Alice, this is not good to eat, it tastes bad.’ But the baby still takes a
bite and she smacks her lips. Mother laughs and says, ‘That’s bad! Now she knows I
was lying to her and she that ice-cream is really delicious.’ Alice wants more and stretches
her hands towards the boy. So he offers her another bite. Alice waves her arms joyfully,
but the mother says to the boy, ‘Thank you but don’t do that again.’ The boy touches
Alice’s face, and then runs away to his mother. …

(Later in this observation) … Grandmother and mother try to take off Alice’s trousers
twice for her to pee while they are walking; Alice refuses twice.

There are complicated cultural aspects in this extract. One central conflict is that
infant observation should be considered as a private event, but the family wants to
make it public – perhaps to show something perhaps to hide something. To some
families, going out, taking a walk, talking to other neighbours can avoid negative
emotions and the embarrassment which may happen in their private interactions
with their babies. Parents also use public spaces to show some particular aspects of
their care-giving. Whereas helping a toddler to pee should be very private, Alice’s
mother chooses to take off her trousers in a public space. It is interesting to specu-
late about the unconscious meaning of this public exposure, or humiliation. It
could reflect the fear of humiliation, shame or losing face referred to earlier.
One may consider that the families decide the observation’s location, in a
similar way to ‘online patients’ who choose the location of their online
 Infant Observation 225

psychotherapy. The decision is made, at least initially, by the patients. In ordin-

ary psychotherapy and psychoanalysis, psychotherapy sessions will almost cer-
tainly be in the analyst’s or therapist’s office or consulting room, and how the
setting and the physical location are experienced by the client or patient will
become evident over time. But in online psychotherapy, therapists might have
limited power and influence over where the patient chooses to be (perhaps
until the patient makes a change without prior discussion, for example). This
raises interesting questions about the meaning of the patient’s choice of location
and whether he tries to have sessions in more than one place. This would be
another aspect of the therapeutic work which would need to be taken up by
the therapist or analyst.
Besides the choice of location, whether the patient would prefer to use ear-
phones or headphones is also meaningful (not an issue in traditional psychother-
apy sessions.). One patient decided not to use earphones in the fourth year of his
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analysis, because he ‘ … began to notice that using it was as if the sound of the
therapist’s voice was coming directly from his own mind (not from the other)’.
In the previous years, he had thought that the earphone could prevent echoes
and guarantee confidentiality so he insisted on using it. When he used the micro-
phone and speaker instead, it enabled him to think with his therapist about his
infantile omnipotent phantasies.
The meanings behind new elements linked with online psychotherapy are dif-
ficult for therapists to examine. Potential dynamics are overlooked. In ordinary
psychotherapy, it is the therapist’s responsibility to provide the frame for the thera-
peutic work, but in online psychotherapy, in the author’s view, it is the two parties
together who create the frame in an intersubjective way. The author suggests that
in the initial phase of online psychotherapy, the counsellor/therapist should try to
take up such issues as the space and environment of the client’s preferred location,
the computer the head phone, and other differences. It will then be possible for the
therapist to take up the difficulties that the patient is having in agreeing to the con-
sistency, and to explore and begin to think about its meaning.

Therapeutic confidentiality
There is one more issue specifically relating to online psychotherapy that of thera-
peutic confidentiality. There may be a number of elements like this:
(1) The client or patient may record the meeting using audio or video soft-
ware. This would be much less visible and could be hidden from the psy-
chotherapist. But it might feel easier or even desirable to the patient, who
might not discuss it with the psychotherapist. Perhaps the psychotherapist
would need to bear this in mind in the initial ‘setting up’ of online
psychotherapy?
 226 X. Wang

(2) There is some possibility of the risk of eavesdropping or of the patient

asking someone to listen in secretly.
(3) The software/device/connection may be hacked, and there might be infor-
mation disclosure.
(4) If the clients do not designate a private space, and sessions, are conducted
in rooms which another person might enter during the session, then part-
ners, colleagues or people sharing the accommodation might hear some of
the material either by accident or intentionally. Again this would seem to
be important to discuss in setting up the therapy in the same way that
space needs to be made for setting up an observation and allowing families
to ask questions and for observers to talk about what might work well and
what might not.
(5) It might be that unconsciously, on the phantasy level, that the client has
chosen a place which is less confidential with the higher risk of infor-
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mation leaking, which might express something about their internal

world. This again underlines the need for discussion and very careful
detailed planning in setting up therapy, just as in observations.

Conclusion
Online psychoanalysis or psychoanalytic psychotherapy offers both new possibili-
ties and potential problems. Such changes may not be fully registered in the thera-
pist’s mind and hence, she may find it more difficult to be fully self-aware or to
think about the countertransference. Some issues like changes in locations and
body gestures may be overlooked, at least initially.
Fortunately, we can learn from our experience of infant observation in our
reflections on online psychoanalysis, just as we do in the conventional form.
Infant observation helps us to understand that there are no set rules for caregivers.
Similarly, there are no set rules for the new activity, online psychoanalysis. One
should be sensitive, observant and open, cautious and abstinent, as one builds a
picture which enables helpful work to be done online.

Acknowledgements
I should like to express my gratitude to Sami Wong (黄申申 in Chinese), a psychologist
who works in a number of settings and also works cross-culturally. Sami Wong helped
with the writing, provided excellent suggestions and offered helpful comments on this
paper.

Disclosure statement
No potential conflict of interest was reported by the author.
 Infant Observation 227
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Life Encounter Psychoanalysis – Specialization Versus Popularization.
Winnicott, D. W. (1960). The theory of the parent–infant relationship. International
Journal of Psycho-Analysis, 41, 585–595.
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