Questioning the Moral Panic Around Teletherapy: An Interview with Hannah Zeavin

Hannah Zeavin is a leading scholar investigating how mediated communications and technology impact our intimate relations. Her most recent work tackles teletherapy and digital mental health communications, which have seen a boon throughout the pandemic.

Zeavin is a Lecturer in the Departments of English and History at the University of California, Berkeley, and affiliated with the Berkeley Center for Science, Technology, Medicine, and Society. Zeavin is also a visiting fellow at the Columbia University Center for the Study of Social Difference. She received her Ph.D. from the Department of Media, Culture, and Communication at NYU in 2018.

Her first book, The Distance Cure: A History of Teletherapy, will be published by MIT Press this summer. Zeavin serves as an editorial associate and author for numerous publications, including the Journal of the American Psychoanalytic Association. She is also a co-founder of The Science, Technology, and Society Futures Initiative.

In this interview, she discusses her upcoming books and all things mediated communication, teletherapy, and technology. Zeavin approaches human relationality, including therapy, from the perspectives of literature and media studies. She explores the history of psychoanalysis and other forms of therapy, garnering fresh insights into our relationship with technology and each other–without the usual moral tenor of psychologists.

She also draws upon her research to discuss how care may take unexpected forms through technologies, enabling distanced intimacy and social change that transcends the psychology of the individual. We close by addressing the feminization of care labor, care as a cover for capture and control, and shifts in how we understand care, now and in the future.

 

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Emaline Friedman: Hannah, your journey spans psychology, technology, media, and society. Why don’t you tell us a little bit about your background and the interests that have shaped your career so far?

Hannah Zeavin: I have had long-standing investments in thinking about media and mediation and the technology that’s charged with carrying out our intimate relations. I think about the psychological work that media and technology do as well as their tangible use in our healthcare landscape and, of course, our mental health care landscape.

I was lucky enough to earn a Ph.D. in an amazing pluralistic department, the NYU Department of Media, Culture, and Communication, which allowed me to really think about these problems synthetically as one problem with all these multiple components. In parallel, I have been involved with psychoanalysis and publishing. I used to work as the managing editor for the Psychoanalytic Quarterly, and now I am the editorial associate of JAPA (Journal of American Psychoanalytic Association). I was also trained to work on a crisis hotline and have volunteered on and off at that hotline here in the Bay Area for about six years, which deeply inflected how I approach this work critically and as a scholar.

In all my work, I am interested in investigating special cases of mediated communication and technology. In my first book, the relationship under consideration is between patient and therapist and media. I wanted to look at a very particular case as a litmus test to think more fully about mediated human relationality in other contexts.

My next book, which is called Mother’s Little Helpers: Technology and the American Family thinks about just that – technology and the relationship between parent and child across more than a century. Additionally, I am committed to questioning forms of relationality that we might approach as a moral good, like notions of intimacy or care, or even empathy, to see what these ways of coming together allow us to have but also what they might conceal, carry, and fully instruct. Teletherapy is also a case that I use to think through questions of how we are with each other and to each other in these modes of interaction.

 

Friedman: Teletherapy seems like a perfect marriage between media theory and the Freudian psychoanalytic tradition. How would you describe your contribution to the history of psychotherapy?

Zeavin: My first book, The Distance Cure: A History of Teletherapy, is probably the formal site of this contribution. I have other writing that is not duplicated in the book that is around its edges.

There, I think about the relationship between therapists (broadly defined) and patients and media. I revise our idea of the therapeutic dyad to argue that we are always working in some version of the triad: patients, therapists, and media and/or technology. That is a major revision to the notion of clinical practice and its premise that it is just people in a room and that, for that reason, it could be considered a pure or unmediated encounter.

I disagree and re-frame it as always being present–that triad. Then, The Distance Cure, makes a few additional interventions by examining the therapist and their patient working at a distance from one another globally. It retells the history of clinical psychology via its shadow form: teletherapy.

Instead of teletherapy being a recent concern, it has been about to make its grand debut for about a hundred years. We have been legislating in front of that and forecasting both great advancement and predicting doom for that whole time. It turns out that teletherapy is as old as the history of therapy itself.

In the first chapter of the book, I argue that psychoanalysis and tele-analysis are concurrently brought to the fore by Sigmund Freud. Not because he was thinking about media metaphorically, which he was, quite famously, but in his real use of media to treat patients at a distance, starting with himself in his so-called self-analysis, which I argue is just a tele-analysis.

Eventually, his first and only child patient, Little Hans, was seen in the office once but was treated otherwise via letter writing. The book takes these extraordinary and vulnerable relationships between therapist and patient to explore what forms of intimacy, knowable and ignorable, are possible in these configurations.

So, to dilate a little bit, I argue that since Freud stopped laying hands on his patients as part of hypnosis, which was the turn to talking, some intervening distance has always been present between patient and therapist, even in the room.

Then I proceed to look at how patients and therapists have bridged that distance for communication to happen at all. Of course, teletherapy and the relationships contained in there physically literalize that separation even as they work extremely hard to diminish it.

As I conducted my research to make a critical history of teletherapy, starting in 1890 and going right up to our present, I found that teletherapy almost always attends crisis, and crisis almost always attends teletherapy. The crises in the book that I look at include World War I, the Spanish Influenza Pandemic, World War II, the war for liberation in Algeria, a suicide epidemic in San Francisco, and even our contemporary pandemic unfolding right now. While these cases are each quite different from one another, I unite them by claiming that distance is not the opposite of presence; absence is.

The entire book focuses on asking: If “tele-” is not an absence or a loss, what is it? The book elaborates various forms of what I call “distanced intimacy.” This is another contribution, I hope, instead of assuming “tele-” is always a hopelessly lesser form of care, although it certainly can be. I investigate this real, 130-year long history of this form to upend that as a base assumption.

Lastly, I think I de-homogenize how we think about teletherapy. I am interested in many media forms and usage across this time period, not just private practice therapists doing zoom or apps for the iPhone. Instead, I try and restore the long history of teletherapy to think about it more holistically.

 

Friedman: In a way, you naturalize teletherapy in your work by presenting distance as always having been an integral part of therapy. I assume you use these arguments to address the recent uptick in panic around distance therapy.

Zeavin: That has been a productive thing that I have been able to do over the course of the last year as clinicians and patients have been worried that we’re moving in a direction that rescinds the availability of the in-person scenario (especially because of the attention given to the “appification” of mental healthcare).

This puts teletherapy and that very cherished way of working together at odds with one another. One thing that the book gently tries to do is show that these cases usually go together. Especially when distance is everywhere, such as in our current moment, teletherapy is not in contradistinction to in-person therapy because there is no in-person therapy or very little.

That is also a way of moving past that moment of panic and thinking more clearly about what might be happening. Of course, I think we all know just anecdotally that panicking can make it hard to think. By stepping away from that edge a little bit, we can discuss this question more fully.

 

Friedman: Are there medium-specific contradictions of therapy that we should be aware of?

Zeavin: Well, the book contends that immediate technologies have always played a central and sometimes alarming role in these intimate relationships. I consider medium-specific forms of relating that allow for unexpected and new (bracket good or bad) kinds of human-to-human connection.

Care is going to look very different when it is being offered contingently and anonymously via the phone in San Francisco in the 1960s than it looks in the hands of an analyst and their patient who have been working together five times a week for a decade or more. The book asks us to really sit with each of these scenarios, especially those that might be thought of as para-therapeutic or activist-based care. It asks us to resist just writing them off as emergency care where nothing really happens, or only bad things happen.

I’ve written elsewhere about the lineages of the crisis hotline and how they flow into contemporary suicide hotlines and policing, where lethal things do happen.

I also try and think about the excess of intimacy that can be encountered in teletherapy because one thing that comes up a lot in the literature on tele-forms of relating is loss: loss of intimacy, loss of empathy, loss of understanding. I think it is important to re-frame these critiques that situate teletherapy as lesser by pointing out that it can be too much. Again, that depends on the medium and the people involved.

For example, I have a colleague who told me that teletherapy, which he’s only practiced in the pandemic, feels like telepathy because of the use of noise-canceling headphones. In fact, there is a little easter egg throughout the book, which is that, again and again, telepathy comes up in conjunction with teletherapy throughout its long history, whether that’s Freud being extremely worried or my colleague here in the Bay Area.

 

Friedman: It reminds me of facilitating on Zoom, where inevitably the facilitator must ask, as in a seance: Hannah, are you here with us? Can you hear us? There is certainly a sort of mediumship involved in that.

Zeavin: That’s a really great example. This is also something that I am invested in; thinking about what the medium outside, I call it the real infrastructural mediums in quotidian, habitual use do and how they interact with what I call the medium inside.

Chris Gilliard’s notion of “digital redlining” is useful here, revealing how access to technology is deeply uneven in this country and beyond this country. Calls do drop, and Zooms do freeze. One of the things that I have begun to work on and notice is how that makes individuals feel differently. That is a medium-specific and an individual-specific thing–how we react to the call dropping in therapy. You know, not just in the “can you hear me now?” sense of the AT&T ad, but somewhere deep inside.

 

Friedman: You mentioned earlier that you really took pains to bracket out the sort of “good or bad,” “for or against,” and the book reads as a balanced approach to the evolution of distance therapy. Yet many practitioners probably bristle at your description of the Talkspace app, where you describe how the immediacy that consumers come to expect from social media apps substitutes for a lot of the facets of the traditional therapeutic alliance.

Zeavin: I bristle at it too. My description is what is there. I think I make it rather clear in the book that I am very worried. Worried is too soft! A word about the slippage where we call the patient a “user” or perhaps worse, a “consumer,” even though, of course, therapy under capital is consumed. And that is probably the start and the end of the set of problems. There is much about the amplification of mental health care and the Uberization of the mental health profession that is deeply troublesome.

We are in a moment of massive job loss, and many of these apps are marketed, not to individuals, although Talkspace is, but to employers. They are “disrupting” mental health care, but these platforms are also constantly collapsing wellness and economic productivity in how they are addressing themselves to the crisis.

We are seeing this all the time in the pandemic. When CEOs or CFOs speak about these apps, often the logic is: “we in the US lose billions of dollars annually from depression, and if we had an app for that, that would be good, right?”

That framing is endemic in Silicon Valley, but not just here: “if we had an app for it or if we could disrupt it, then we could fix it.” The mental health “industry” is what those in Silicon Valley name as ready for disruption in this “space.” These are the kind of buzz words that I hear a lot.

Another problem is what is expected of those employed to do the caring, providing therapeutic labor on those platforms. Journalists Kashmir Hill of the New York Times and Molly Fischer of New York Magazine have most recently done pretty deep investigations into the clinician experience. And we have to care about that, too. I care first and foremost about patients in this book and my life, but I also care about therapeutic labor.

A high level of care at a lower price is what is on offer for the patient, even if it’s packaged differently. But that is what subtends these apps, and that is what the disruption might be. There’s endless anecdotal evidence that whether it is the gender preference of the therapist or their cultural competency, a promise of on-demand care, or a promise of availability, these things generally don’t come to fruition, and then they hurt everyone.

If someone is at the point of needing care (especially in this country) and seeking it, and then it is not delivered, or it is misdelivered, that is a real problem. There’s relatively little oversight. As employees or students, we might be told to use an app to achieve wellness, whatever that might be, and to mind our own wellness. This is an unfortunate defending of the political notions of self-care, turned into a hashtag, and that language itself skirts therapy on purpose. If the intervention is wellness or care or companionship or coaching, it might do something good or bad, but it is not therapy, and it’s not being regulated as such.

 

Friedman: It certainly is not. The immediacy expectation cuts both ways because when you strip the reasonable or favorable working conditions of mental health workers, the quality of care also suffers. If you could distill a message to mental health workers from your book, what would it be?

Zeavin: In addition to this idea of thinking through the triad as always being there, one message to clinicians and mental health care workers is that there are longstanding crises that we must address in mental health care. It is not just because we’re here in a pandemic, or because we’re at the latest moment in late-stage capitalism, or because of the application of mental health care.

The emergency switch to Zoom a year ago and the apps that are under the mindfulness category on Google play are not the sum-total of the history of teletherapy. I want us to be able to think more deeply about how we might relate over a distance without feeling resigned to a future of corporate wellness initiatives. There is a whole radical, careful history of teletherapy starting with Freud himself that can really point the way.

 

Friedman: I am reminded of what comes up in your book around mass intimacy and broadcast forms of mental health care delivery, as well as the challenges suicide hotlines and other crisis hotlines, pose to traditional therapy. Are there facets of your work that gesture toward a future where care for the psyche is a little bit more of an open venture, perhaps even non-commercial?

Zeavin: Of course, this would be utopian. On the other hand, it has always already existed, so I have to hope it’s to come. The book does end with reference to the Shockwave Rider, a dystopian sci-fi novel by John Brunner. The book has a complicated plot, but the setting is one of total control by the government. On the edges of that control also exists little forms of resistance. In some ways, it is a pretty Foucauldian book.

The fictional form of care depicted in the book is called the hearing aid, a collective of telephone service operators reached at (999) 999-9999. It works a lot like the crisis hotlines that I have worked on, which might be why it got inside me. In the book, callers will scream into the hotline, or they’ll have a longer episode where they’re talking endlessly. Some callers also use the hotline for a witnessing function as they take their own lives because the dystopia is that extreme in this book. So, telecare is imagined as functioning, even at the bitterest of ends.

Even in the most dystopian societies, we understand that there will be some form of tele-help.  A major difference between real-world hotlines and this hearing aid is that the hearing aid operators don’t talk back to their callers, and they end each call with quotes only.

That closing really stuck with me because, at that space at the edge (you want to call it the culmination of 500 years of the crisis of white supremacy), we will take these various unique forms of communication amid crisis and suffering and continue to need them.

That is not what I would call a more open venture in a happy sense. I am trying to suggest that even when we imagine the worst possible outcomes for our world, and many argue we are living them, we also can imagine how we will navigate them psychically, together. The thing I am excited by in my book is that teletherapy, up until COVID-19, was almost always a free service or low fee.

That also means we must think about how less good care might be pushed onto communities that are already vulnerable via a supposed “democratizing process” of access. Access is one of these words that we need to complicate and not just take at face value.

In my book, these historical cases talk about communities doing it for themselves, where care is articulated specifically toward actual people and their actual needs. Whether it is those historical cases or the revived interest in the long-standing tradition of mutual aid during the pandemic, or apps that are being made by people like Rashaad Newsome, who’s working on an app to respond directly to the rage and depression that black communities are facing in the wake of police murders and racial aggression, I do think that there are discrete examples of how we can be together that don’t rely on this notion of “purity” of being in person, although that’s great, too.

 

Friedman: Contrary to the notion of purity in the psychoanalytic dyad as the highest standard of intimacy and care, one can complicate that by looking at care as a bottom-up process of mutual aid. Yet, there is also a history of psychoanalysis that is profoundly tied to the rise of consumer capitalism. I am thinking about how psychoanalysts have often been astute cultural commentators, but that their theories have had profound impacts on advertising, as in the work of Freud’s nephew, Edward Bernays. What does psychoanalysis have to offer today to the larger digital media landscape?

Zeavin: I think it still has to offer what it has always offered, which is a way of navigating the cyclical effects, both fantastical and real, of what is put into us. Digital media is now deeply part of that and has been for quite some time. There’s incredible work on the psychical effects of new media and digital media. Jacob Johansson, Alexandra Lemme, Aaron Balick, and Patricia Clough have all discussed similar questions about the unconscious and contemporary digital media. Especially the recent book, The User Unconscious by Clough. These thinkers are working in really different ways.

But I think I am purposely misunderstanding your question, which is less about a diagnosis of the landscape and what it is doing to us and more about becoming part of it. That I will demure on because they need no help.

 

Friedman: Having noticed sprinklings of feminist scholarship across your work, I wanted to ask if there are gender differentials that you want our listeners to be aware of in this whole technological landscape that we have been discussing? I understand you are looking at technology in American families in your next book.

Zeavin: Feminist theory, feminist media history, and feminist histories of technology are deeply at the center of how I think, and feminist science and technology studies are deeply at the center of how I was trained. I think it can seem to be outside the scope of mental health care, but for me, it is not.

My next book is called Mother’s Little Helpers: Technology in the American Family. That book is focused on the ideas of maternal absence and presence and medical redlining as they interrelate to the real use of technologies in families…or not. I also deal with media refusal and technology refusal in the book as well.

In terms of mental health care, I think we can say that part of this story is the feminization of therapeutic labor and the masculinization of technological and clerical work. All of this is doubly crucial to the history of teletherapy.

The book tells a story, that is not just a chronology, of the increased turn to what some call “de-expertise” or “de-skilling,” although I push back against that, of the therapeutic encounter across the whole history of the 20th century. The book does not only deal with psychoanalysis. Feminization of therapeutic labor also means that women were increasingly becoming therapists and psychoanalysts, which is also part of the story of the Uberization of therapy.

Beyond teletherapy, but within it, care can function as a cover for capture and control. That stuff impacts us all, however unevenly. Gender is a huge question, but so are things like race, class, ability, and saneism in this area. We can ask how social change via the new technology interacts with the psyche and the body and the individual, but this is all grounded in questions of what is happening more systemically, beyond the individual, in society.

 

 

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MIA Reports are supported, in part, by a grant from the Open Society Foundations