Developing a Reflective Self in Cyber Space

Developing a Reflective Self in Cyber Space
Shoshana Ringel, PhD
University of Maryland, Baltimore
Faye Mishna, PhD
University of Toronto
Jane Sanders, MSW
University of Toronto
This article will address how cyber technology may facilitate reflective functioning with patients who
present with primitive self states, fragmentation, and dissociation. The utilization of text-based information and communication technology may allow for a reflective space, apart from the therapist’s
explicit intrusion and the potential danger of abandonment and rejection, and may help develop the
capacity for reflection and symbolization. Through a case illustration and research findings, we will
discuss the benefits and challenges of using cyber technology as an adjunct to face to face treatment.1
Keywords: cyber technology, reflective functioning, dissociation, attachment, borderline personality
disorder
The purpose of this article is to discuss how text-based forms of
communication using cyber technology may facilitate reflective
functioning with patients who present with primitive self states,
fragmentation and dissociation. The utilization of text-based information and communication technology (ICT) may allow for a
reflective space, apart from the therapist’s explicit intrusion and
the potential danger of abandonment and rejection, and may help
develop the capacity for reflection and symbolization. For patients
who may be hypervigilant during a face-to-face therapeutic encounter, cyber communication can allow for the development of
the capacity for reflection and symbolization that can otherwise be
overwhelmed by affective instability and ongoing crises during
direct proximal interactions. A case illustration will highlight the
use of e-mail to foster more open expression, allowing space for
deeper reflection that can be further strengthened when brought
into the face to face therapeutic process.
Janet (1925) was one of the first clinicians to distinguish between normal narrative memory in which familiar experiences are
stored and integrated into narrative sequence, and traumatic memory, in which frightening or novel experience sustains “particular
vividness” (van der Kolk, 2002) and may remain fragmented and
dissociated. While in some cases, these memories are dissociated,
discrete aspects may later manifest through enactments, intense
affective response, nightmares, images, or sensorimotor experience (van der Kolk, 2002). Bromberg (2011) suggests that during
dissociative episodes, fragmented self states in the patient may
trigger dissociation in the analyst, and that the analytic dyad then
engages in mutually dissociated enactments that might be recognized and processed only at a later point in the treatment.
Fragmentation and dissociation may develop in the context of
attachment insecurity and disorganization when fear is a dominant
affect in the attachment system following inconsistent and unreliable responsiveness by primary caregivers on whom the child is
dependent for care and survival (Slade, 2014). The child may then
develop affective and behavioral strategies, such as aggressive
behaviors or anxiety, to manage rejection, shaming, and lack of
attunement by the caregiver (Lyons-Ruth, Dutra, Schuder, & Bianchi, 2006). Such child–parent interactions foreshadow the
patient–therapist relationship, which may mirror earlier relational
trauma associated with perceived rejection and fear of abandonment. A pattern of ongoing crisis and disruption in the therapeutic
bond may interfere with the potential space that typically develops
in the context of attachment safety and security, and allows for the
development of insight and mentalization functions (Fonagy &
Bateman, 2008). With these patients, face-to-face interactions may
at times be too destabilizing to allow both the patient and the
therapist to utilize their reflective capacities.1
Information and Communication Technology (ICT)
in Therapy
The rapid increase of information and communication technology has revolutionized how individuals of all ages interact
(Migone, 2013; Perron, Taylor, Glass, & Margerum-Leys, 2010).
Along with the tremendous accessibility and ease of online messaging, there has been a transformational emergence and popularity of social networking sites, such as Twitter, Facebook, Tumblr,
and Instagram, among many others. The number of users worldwide has increased exponentially, as have the ever expanding local
1 A shorter version of this article was presented at the 2015, IARPP 12th
Annual Conference, Toronto, Canada.
This article was published Online First September 26, 2016.
Shoshana Ringel, PhD, School of Social Work, University of Maryland,
Baltimore; Faye Mishna, PhD, Factor-Inwentash Faculty of Social Work,
University of Toronto; Jane Sanders, MSW, Factor-Inwentash Faculty of
Social Work, University of Toronto.
Correspondence concerning this article should be addressed to Shoshana
Ringel, PhD, 1915 Greenberry Road, Baltimore, MD 21209. E-mail:
[email protected]
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Psychoanalytic Psychology © 2016 American Psychological Association
2017, Vol. 34, No. 1, 87–95 0736-9735/17/$12.00 http://dx.doi.org/10.1037/pap0000113
87
and global networks and opportunities for learning, entertainment,
and support (Blais, Craig, Pepler, & Connolly, 2008; Mishna,
Bogo, Root, & Fantus, 2014).
With the exponential increase of handheld devices, individuals
of all ages now utilize text-based communication with fluency and
ease. Moreover, ICTs have led to transformative changes across
professional fields (Bradley, Hendricks, Lock, Whiting, & Parr,
2011; Tunick, Mednick, & Conroy, 2011). There is a growing
body of literature on formal ICT programs and interventions, such
as e-counseling and telepsychology (Dowling & Rickwood, 2013;
Hanley, 2009; Richards & Vigano, 2013). In formal ICT interventions, ICT is typically the standalone mode of service provision. In
this model of service delivery, online/e-therapy consists of interventions or support offered through synchronous (e.g., chat) or
asynchronous (e.g., e-mail) communication, with encryption and
firewall protections to ensure confidentiality (Abbott, Klein, &
Ciechomski, 2008; Murphy et al., 2009). Online therapeutic interventions have been found to be effective (Barak, Hen, BonielNissim, & Shapira, 2008; Dunn, 2012) and the therapeutic relationship/alliance in e-therapy has been found to be equivalent
overall to that in traditional face-to-face therapy (Hanley, 2009;
Preschl, Maercker, & Wagner, 2011).
In addition to formal online programs, ICTs have become integrated into therapeutic interventions through formal blending of
online modules with face-to-face therapy (van der Vaart et al.,
2014). This model of intervention combines online interventions
and strategies with face-to-face sessions, whereby part of the
intervention entails some online programs or exercises in addition
to or replacing a number of face-to-face sessions. Both the online
and the face-to-face components are formal, structured, and monitored. Online exercises may include homework assignments, psychoeducational activities, or assessment tools.
In contrast to this structured use of ICT in therapy, the current
article will consider the use of less structured, “informal” (Mishna,
Fantus, & McInroy, 2016) or “adjunctive” (Peterson & Beck,
2003) use of text-based communication technology, within the
therapeutic environment. As cyber technology has increasingly
begun to filter into the clinical environment it is fast becoming an
informal part of traditional face-to-face therapy as well, for administrative purposes and as a therapeutic exchange between therapists and clients (Gabbard, Kassaw, & Perez-Garcia, 2011;
Mishna, Bogo, Root, Sawyer, & Khoury-kassabri, 2012; Mishna,
Bogo, & Sawyer, 2015). Specifically, information and communication technology has begun to become incorporated into traditional therapeutic practice as an informal concurrent mode of
communication, an adjunct to the face-to-face sessions or contact.
The reference to this use of technology as “informal” is not to
suggest it is, or should be, untethered to the analytic processes of
therapy. Rather, as an adjunct to face-to-face therapy, any use of
ICT should be incorporated into the context of the analytic process
and given as careful consideration as any other intervention or
therapeutic interaction (Gabbard, 2001; Peterson & Beck, 2003). It
seems that even in face-to-face therapeutic practice, text-based
communication is becoming increasingly inevitable (Gabbard et
al., 2011; Leibert, Archer, Munson, & York, 2006).
Despite the increased informal ICT use in face-to-face therapeutic practice, there is a lack of scholarly work on its benefits,
issues, and implications for practice (Gabbard et al., 2011; Mishna
et al., 2014; Mishna et al., 2012; Mishna, Levine, Bogo, & Van
Wert, 2013). The majority of research examining ICT and therapy
has examined formal online/e-therapy interventions. The most
frequently studied therapeutic use of ICT involves clinical trials of
CBT, and it is unclear the extent to which ICT has been incorporated into therapeutic settings across theoretical approaches (de
Bitencourt Machado et al., 2016). The primary concern identified
in the use of ICT in psychoanalysis is the loss of direct physical
context or nonverbal feedback in the communication, potentially
influencing the interpreted meaning of an exchange (de Bitencourt
Machado et al., 2016). The informal incorporation of ICT communication into face-to-face therapy is unique. The dialogue can
continue in the next session allowing multiple meanings to be
clarified and the experiences of both the therapist and client can be
analyzed with access to verbal and nonverbal information when
appropriate. Scholarly work on ICT and mental health has examined smart phone applications and texting as supplementary intervention tools for specific populations. Addressing the issue of the
informal use of ICT, Mishna and colleagues (Mishna et al., 2014;
Mishna et al., 2012) conducted a two-phase qualitative study on
information and technology usage among clinical social workers,
in order to examine how cyber communication has “crept” into
traditional face-to-face practice. Analysis of focus groups with a
total of 31 practitioners found that traditional face-to-face practice
has been transformed by ICT, and that it is no longer possible not
to engage in the use of ICT.
In Phase 1 of the study, 16 practitioners took part in focus
groups. Findings indicated that the participants considered ICT
beneficial for administrative purposes such as scheduling appointments and conveying information about resources.
These same participants were invited to participate in focus
groups in Phase 2 and nine of the 16 were reinterviewed. Additional participants were recruited, with two criteria consisting of
being less than 35-years-old (to ensure a younger cohort, which is
considered relevant when examining ICT use) and having practiced in social work for fewer than 5 years. It became evident in
phase two of the study that the practitioners who had participated
in Phase 1 had shifted in their views; in addition to finding ICT
useful for administrative purposes they had come to find ICT also
provided a new dimension in their practice, offering continuity of
the therapeutic relationship through extending the session. According to respondents who had participated in Phase 1, “for this client
knowing she can connect with me on e-mail is very meaningful.
Someone is hearing her. She has found someone she can trust;”
and “Clients take strength in feeling they are connected to you”
(Mishna et al., 2014, p. 182). This new dimension also was
identified by respondents as helping clients process their thoughts
and emotions and self-regulate. One practitioner stated for example “some clients write their thoughts after the session. It helps
them process and reflect on issues” (Mishna et al., 2014, 183).
Another commented
They’re e-mailing me to say ‘I need to share this with you.’ It takes
a bit of a burden off their shoulders. The stress and the anxiety of
whatever they’re suffering can be alleviated or decreased knowing
that ‘okay, I’ve shared, and I am able to now let this go until I see
xxx’. (p. 183)
Participants also discussed challenges and contemplated how
they could adapt ethical and clinical standards to the new reality of
practice. In contrast to their previous reactivity to clients’ contact
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88 RINGEL, MISHNA, AND SANDERS
through ICT, experienced practitioners described anticipating the
dramatic change in expectations related to the availability due to
the ubiquity of ICT. As an example a respondent described explaining “in a clear, kind, emotionally present way that I know
there are times when the client may want to reach me, and while
I would like to be available, I cannot be at all times” (Mishna et al.,
2014, p. 183). Importantly the experienced practitioners recognized that it was necessary to address boundaries in an ongoing
manner rather than only initially: “I revisit my boundaries as many
times as I have to” (p. 183). The young and new practitioners,
while clearly understanding the benefits of ICT, recognized the
challenges, as evident by one respondent’s comment that “it makes
it a little bit stickier to keep the professional boundaries” (Mishna
et al., 2014, p. 183). Some of these respondents explained that one
way they manage boundaries is by having a separate phone and/or
Facebook or Twitter account which they use only for work. Moreover, they explain to their teenage clients, “While I’m very
friendly, my role is not to be your friend, but to help you find
friends” (p. 183).
Although the Internet and social media have taken a central role
in communication during the last decade, utilizing online text
communication in the analytic process is still relatively novel. In
this article we posit that this mode of communication may enhance
the patient’s reflective capacities by providing a safe forum in
which to express dissociated affects and self states, and to reflect
on one’s states of mind within a less intrusive relational context.
We use a case illustration to demonstrate (S.R.).2
Case Illustration (S.R.)
Donna is a professional woman, who presented with extensive
dissociative episodes related to experiences of rejection and abandonment. She attributed her poor ability to regulate her affect,
anxiety regarding intimate others, and fear of abandonment, to her
attachment history. Though initially very close to her mother,
Donna reported that her life radically changed at 19 months when
her sister was born, and, according to her mother, Donna became
an anxious, demanding, and dysregulated child. Donna recalled an
emotionally absent mother and a father consumed with his career.
As a child, she remembered her parents as helpless and preoccupied, and as typically ignoring her and siding with her sister
whenever the two argued or fought with each other. Donna recalled that she would become angry and even violent at this
perceived injustice, and that her parents responded by helplessly
accommodating, letting her have her way and buying her gifts.
Sometimes however, they locked her in the dark basement until
she calmed down. One vivid memory of Donna’s was trying to
reach out from underneath the basement door and crying, but no
one came. This formative event became Donna’s organizing principle, that others found her to be too much, and looked for ways to
get rid of her. Sadly, she continued to enact this relational configuration with lovers, friends, therapists, and with me (S.R.) as she
became increasingly more demanding and affectively dysregulated
and they in turn felt overwhelmed, resentful and then withdrew,
eventually terminating their relationship with her. Donna’s hypervigilance to maternal affect and responsiveness interfered with the
development of affect regulation skills and the ability to recognize
her own internal states. Rather, she continually strove to please and
achieve, which was the only way for her to gain her mother’s
validation, as a way of getting love and acceptance from others.
Donna learned that the way to gain attention and responsiveness
was either through academic, athletic, and professional achievements, or by engaging in extreme behaviors, such as threatening
suicide and having regressive meltdowns. She described periods of
intense despair and suicidality triggered by fear that she would be
abandoned by intimate others. During these times Donna frequently dissociated, and resorted to self-injurious behaviors, such
as cutting and scratching herself, and states of rage and aggression,
which were later recounted to her by others as she did not remember these states. It is significant that in the midst of periods of
suicidality and dissociation, Donna was able to hold a demanding
professional job in the mental health field and to function well in
her position (van der Hart, Nijenhuis, Steele, & Brown, 2004).
Often, when she shared her insights regarding the children and
parents with whom she worked, I (S.R.) felt deeply moved by her
empathy and understanding for her severely abused, neglected and
traumatized patients. Donna empathized with her patients’ lives of
despair and isolation through her own early and largely unformulated experience, which she often could not articulate, but was able
to relive and symbolize through her narratives about her patients.
Diverse self-states became activated during the treatment, including the abandoned and desperate child, the impulsive, suicidal
and at times superficial adolescent, as well as an insightful and
reflective adult self-state, which was mostly expressed through
e-mails and through Donna’s description and understanding of her
patients. While the therapy began as twice weekly face-to-face
treatment, I decided over time to develop a more flexible treatment
frame that would offer greater holding and containment for Donna’s unregulated affects and self states. This included face-to-face
sessions, crisis telephone calls as needed, occasional sessions with
Donna and her partner, and eventually cyber communication. This
array of options made it possible for us to observe, and engage
with a range of Donna’s affects and self-states that may not have
been available if there had been rigid adherence to a traditional
treatment frame (Weisel-Barth, 2011). I believe that my availability and a flexible treatment frame was fundamental for Donna’s
treatment, though it also presented considerable challenges, as will
be discussed below.
The fluid treatment strategy offered Donna greater safety, holding, and control, and a room for broader affective expression, and
she demonstrated a growing capacity to become aware of her
conflicting self-states. During the treatment process, I often experienced feelings of depletion and even apprehension of Donna’s
escalating logistical and affective demands. I also feared potential
conflicts and disruptions that might emerge because of Donna’s
vulnerability to any perceived rejection and affective withdrawal
and her intense fear and expectation that she would be abandoned.
Another concern for me was that expanding the treatment frame
beyond twice weekly sessions would eventually become unmanageable.
I will discuss how the individual face-to-face sessions augmented with e-mail communication appeared to facilitate the development of Donna’s reflective functioning and capacity to become more aware of her affective shifts. In the concluding
2 All identifying information has been changed to ensure confidentiality.
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SELF STATES IN CYBER SPACE 89
discussion, we will also discuss the challenges for the therapist in
utilizing e-mail as an adjunct to the face-to-face sessions.
Clinical Process
During sessions, Donna often appeared to be in a regressive
state, speaking in a childlike manner as she recounted her daily
activities, or curled on the couch in a fetal position, feeling
hopeless and despairing. She often gazed at me silently for long
periods of time, watching my every move as if to make sure that
I was present with her and fully attentive. She seemed to take me
in like a very young child who relied on her sensory, tactile, and
visual system to establish contact, and to feel held and secure
(Beebe & Lachmann, 2014, 1994). This early developmental state
was also apparent in Donna’s focus on concrete details and events,
and her inability to engage in more symbolic communication. She
never remembered her dreams, and rarely shared her affective
experience. We started to develop connections and internal structures through implicit, sensory, and bodily communication, often
in silence, rather than through words, symbolization, or affective
explorations (Grossmark, 2012). At times, Donna invited me to sit
on the couch besides her as she showed her photos of friends and
family. She did not describe the people or the nature of her
relationship to them; rather, she just stated their names, as if
inviting me to be a witness as we both quietly set next to one
another. Donna desperately sought physical proximity and sensory
connection, trying to avoid the possibility of being locked out and
abandoned in the darkness. She repeatedly reminded me that as a
child, she was rarely touched. She experienced this deprivation
viscerally, and it was the most painful aspect of her lover’s
rejection. She told me how she sniffed her lover’s pillow, and held
it as she fell asleep alone, imagining that her lover was still with
her.
At other times, Donna became enraged or suicidal, blaming me
for not doing enough and demanding that I actively intervene in
her conflicts with her partner, answer her despairing phone calls
immediately, and allow her to remain in the office as long as she
needed. Donna lacked self soothing and affect regulation skills,
which develop in the context of parent– child affective interactions, and constantly sought others to help regulate her through
physical holding and sensory connection (Beebe & Lachmann,
2014). When this holding was withheld, Donna engaged in selfharming behaviors such as cutting, to help regulate her extreme
affective shifts. At other times, however, Donna showed considerable reflective skills as she described her own patients, and
shared her deep understanding for their traumatic experiences. For
example, Donna told me about a boy to whom she became extremely attached, who was severely abused and neglected, and
whose adoptive mother rarely touched or held him. Donna described how the boy often became violent and destructive, incurring further punishment and rejection by his mother. Donna understood the boy’s desperate loneliness and frustration. She held
him, as she herself wished to be held, verbalized to him his anger
and despair, and taught his mother to be more loving so as to repair
the severe neglect and abuse he has experienced. Through her
relationship with the boy and his adoptive mother, Donna tried to
repair her own lonely childhood and lack of physical and emotional touch, as well as her violent attempts to gain love and
attention.
I found myself in shifting affective states in response to Donna.
During their periods of silent, implicit communication, when I
experienced Donna as a young child who was frightened, desperate, and in need of reassurance and holding (Beebe, Lachmann,
Markese, & Bahrick, 2012), I felt close to and protective of Donna.
I was deeply touched by Donna’s thoughtful and empathic feelings
toward her patients. However, I also found myself accommodating
Donna’s demands for her time and flexibility to a point well
beyond my personal and professional limits. Consequently, I often
felt overwhelmed and resentful, and eventually started to withdraw. This entailed no longer answering Donna’s phone calls
between sessions, and feeling distant and disconnected from her
during sessions. Not quite aware of the enactment taking place
between us, I did not disclose to Donna my conflicting feelings.
Donna, noticing my affective withdrawal, responded to this sequence by crying and apologizing, terrified that I would “fire” her
as had several of her previous therapists.
We enacted an old familiar dance, similar to the pattern in which
Donna engaged with her mother and her partner. Like me, Donna’s
partner initially accommodated her, only to eventually feel resentful and withdraw in response to Donna’s intense and never-ending
needs and demands. As I became more aware of what was enacted
between us, I decided to abandon the “illusion of analytic attunement” and perfect emotional holding (Slochower, 1996, p. 323),
and rather, to share with Donna my subjective experience. While
I felt it was important to hold and connect with Donna’s primitive
self-states, I recognized that we both needed to maintain limits and
boundaries in order to preserve the treatment, and in order to
preserve my own capacity to survive the treatment (Winnicott,
1963). This shift from the “habitual” therapeutic mode could be
considered a “now moment” as it was a spontaneous response
which allowed an opening or an expansion of the therapeutic field
between Donna and myself (Stern et al., 1998). During the intense
interaction that took place between us I shared my frustration and
sense of depletion as a response to Donna’s demands and expectations. Donna expressed her disappointment in me, and her fear of
being rejected and abandoned. This emotional exchange between
us led to greater openness as Donna became more attuned to her
own affective states, and more concerned about preserving me
(Beebe & Lachmann, 2014).
In a recent article, Aron and Atlas (2015) assert that enactments
are not only a replay of past relational patterns and encounters, but
are also an improvisational mode for future engagements (Ringstrom, 2007). In that sense, enactments encapsulate both the old
and the new, and contain possibilities for the leading edge of
relational change (Tolpin, 2007). Our spontaneous exchange of the
subjective experience between us allowed us to shift from ongoing
enactment of old patterns of demand and withdrawal, to new
relational possibilities of mutuality and affective sharing. This
interaction contributed to Donna’s capacity to symbolize, reflect,
and become more aware of the other’s affective experience. She
became more curious about her experience of herself alone and in
relation to another and she gradually, and spontaneously, proceeded to share her insights with me via e-mails (Fonagy &
Bateman, 2008; Fonagy, Gergely, Jurist, & Target, 2002). Rather
than remaining trapped in a pattern of mutual accommodation, it
became possible for us to express aversive affects and sustain
emotional collisions. It ultimately led to a more authentic and
reciprocal relationship.
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90 RINGEL, MISHNA, AND SANDERS
Donna started to send me e-mails on her own volition, and her
e-mail communications became an integral, though unplanned
aspect of the treatment. As I read her e-mails, I recognized that this
form of indirect communication allowed Donna to access greater
capacity to reflect and symbolize her experience and to contain her
affect, and therefore encouraged Donna to continue. While I did
not actively respond to these e-mails except to acknowledge them
(e-mailing Donna that I had received her message and would
discuss it with her in the following session), I tried to engage
Donna during subsequent sessions, not always successfully, in
elaborating and expanding on their meaning. In her e-mails, Donna
reflected on her affective states, dissociative triggers, and relational difficulties, and she became more aware of her affective
shifts and inner experience in response to relational interactions.
The disembodied cyber communication allowed both Donna and I
to move from a stance of crisis management and intense affective
engagement to mutual reflection and curiosity regarding Donna’s
dissociative episodes and her need for touch and holding, and over
time, offered Donna the possibility of greater awareness and integration.
Donna’s E-Mails
While we discussed her e-mails in subsequent sessions, I did not
engage Donna with an inquiry about her experience of composing
and sending her e-mails. I believed that such inquiry would be
experienced by her as intrusion on her private reflective space, and
on her emerging capacity to be curious about her own inner world.
I recognized that an unobtrusive stance was required to help Donna
shift from a more primitive, fragmented self experience to greater
integration and affective stability (Grossmark, 2012). I encouraged
Donna, however, to reflect and elaborate on the meaning of her
e-mails, and Donna gradually became more willing to discuss the
content of her communications in relation to her subjective and
relational experience. The following e-mail arrived after our discussion of Winnicott’s transitional object in relation to Donna’s
need for holding and affection:
One of the things going on with me is that idea that I am empty and
I find myself in another, so when I lose a romantic partner I am
actually losing a piece of myself. In some ways I can see it being
beneficial to have something to hold and hug when she is not there
that she gave to me or I identify with her. On the other hand, I can see
this being detrimental as one of my goals is to be able to gain an
independent sense of self that is not tied to another human being.
While reading this e-mail, I was struck by Donna’s ability to
articulate and reflect on her subjective experience and affective
needs. Her e-mail indicated that Donna seemed aware of her
primitive need for merger and longing for dependence and had
started to recognize that this interfered with her simultaneous quest
for adult autonomy and agency. When I shared my observations
with her in the following session, Donna dismissively responded
that she had copied her words directly from Wikipedia. She
seemed to disavow her online reflections as if this was an alien
self-state, or perhaps to discourage me from being too hopeful for
her potential recovery and eventual termination, thereby threatening the growing but fragile therapeutic bond.
Possibly, the fabrication from Wikipedia was akin to the development of a “false self” in an attempt to find an alternative way to
be recognized and appreciated by the therapist (Gabbard, 2001).
Indeed, during this period of the treatment, I often felt overwhelmed and depleted by Donna’s affective instability, self-harm,
and suicidal threats, as well as her demand that I be available either
personally or by phone whenever a crisis occurred. Although not
aware of my motives at the time, my encouragement of cyber
communication may have also been an inadvertent attempt at
self-preservation.
As Donna continued to engage in online communications, however, her e-mails began to suggest greater authenticity, and seemed
to enable Donna to maintain a reflective space. Such space was
often not possible during sessions, when intersubjective affects,
her longing to be held and feel connected, and her fear of rejection
and abandonment interfered with Donna’s capacity to utilize her
reflective functions. In her next e-mail, Donna started to recognize
the process of fragmentation that often accompanied and followed
painful and frightening relational experiences, and observed her
emerging capacity to be more present during dissociative episodes:
I guess I am just interested in exactly what I am going through… being
so high functioning and effective one minute but then having a GAF drop
about 60 points to the point of being completely nonfunctional at perceived rejection or abandonment by a significant other. I guess the only
way I can describe this change is a form of dissociation and it was
complete in the past, like another person takes over. Now, though, when
I get into the state, I know cognitively what’s going on, that these are bad
choices, but I feel fully and totally unable to stop them. I do not think I
ever labeled this as dissociation until this year . . . So I’m confused, but
I guess that is what makes me unique is that things are happening
concurrently… literally, I can step into the car after a session (during
work) as an adult, get my partner on the phone and fall back into that state
in a matter of seconds… please let me know your thoughts.
Donna was clearly quite excited about her new insight, which
she wanted to share with me. In the following session, we reflected
together on her dissociative triggers, and we discussed how dissociative processes manifested during the session when Donna
perceived my affective withdrawal and became flooded by fear of
loss and abandonment.
Incrementally, Donna started to be aware of, and remember
regressive self-states although she continued to feel she had no
control over these. Previously she had no memory of such episodes, and would later experience deep shame when they emerged
and were commented upon by others. She was beginning to maintain her reflective function even during times of extreme fear and
distress. Donna then sent me a note she had e-mailed to her partner
so we could discuss it in the following session. In this e-mail, she
seemed to connect with her own experiences of loss and rejection
so as to facilitate a process of empathic resonance with her partner’s state of mind (Fonagy et al., 2002):
We did a powerful exercise in group last week where they asked us to
see the world through someone else’s eyes and I thought of you (her
partner). And what you were brought me to tears in a way I have
never experienced before with any other person. I saw the world
through the eyes of a small girl who was hurt by feeling unwanted and
being hurt over and over again by someone she trusted. And then
trying to express her pain and having no one listen or help her.
Donna wanted me to see that she had started to develop a
capacity to know and understand her partner’s experience and
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SELF STATES IN CYBER SPACE 91
emotional pain and rejection. This was a significant shift for
Donna, who, although empathic in her professional life, was typically preoccupied by her own needs and thus unable to be aware
of those of others. Donna was able to empathize with her partner’s
experience in the relationship and to recognize her partner’s own
childhood trauma and emotional fragility.
In these e-mails, Donna appeared to ponder her responses to
relational disruptions, her dissociative shifts, and another person’s
state of mind related to grief and attachment trauma. This gave me
and Donna the opportunity to create an affective and temporal
protected space from impending crisis, emotional flooding, and
dissociation, and to utilize ongoing awareness as well as reflective
functioning (Straker, 2011). Donna’s desire to please and her
vigilance of my expressions and responses did not interfere or
hover over our communication process. As a child who had to be
ever watchful for her mother’s inconsistent attentiveness, worried
that she may be forgotten and abandoned at any moment, Donna
became anxious and apprehensive during face-to-face encounters
with me, wondering for instance, why my gaze seemed distracted,
whether I was looking at the clock, and why I seemed to move my
chair further away. She found it difficult to tolerate any signal of
withdrawal or rejection, and was hyperattuned to any shift in the
implicit relational processes between us. During our online exchanges, the threat of my subjectivity receded (Grossmark, 2012),
although I remained present as a disembodied witness, providing
Donna with affective holding and validation (Mishna et al., 2015).
Online communication thus became a potential space that allowed
Donna to develop insight and to reflect on her experience while
freeing her from anxiety and vigilance in the presence of the other.
When I asked Donna for her permission to write this article, she
became very enthusiastic, at some point even proposing to travel to
the conference where this article was to be presented (that did not
happened for a number of reasons). I shared with Donna an initial
version of the clinical portions of this article, and she offered some
revisions of her own, pleased that some of her own words were
included verbatim. In a sense, it was a mutual endeavor to which
both of us contributed.
Discussion
Although the use of information and communication technology
as an informal adjunct to face-to-face therapy is in its early stages,
some literature identifies potential benefits, such as continuity in
the therapeutic relationship (Mishna et al., 2015). An additional
benefit is the greater ease offered for patients who may have
difficulty expressing themselves in person. For example, patients
who are guarded during face-to-face sessions may send e-mails
after a session or before the following session in which they
express themselves more fully (Mishna et al., 2012). Cyber technology can thus assist communication in the therapeutic setting
and be used as an informal adjunctive method through which
patients can engage more fully with the therapist (Bradley &
Hendricks, 2009; Rochlen, Zack, & Speyer, 2004).
Cyber communication may provide some patients with temporal
and proximal space to reflect upon their state of mind (Wright,
2002). As was the case with Donna, it can allow the freedom to
express oneself with a level of openness that is difficult for some
to tolerate in the physical presence of the therapist (Gabbard,
2001). Writing e-mails has been compared with keeping a journal
or a diary. Although journaling and letter writing is generally
accepted into the realm of psychotherapy, there remains little
known about the mechanisms through which these means achieve
positive results (Kerner & Fitzpatrick, 2007). Text-based cyber
communication can help support and empower the patient, and be
a way to “enhance self-reflection and ownership of the therapeutic
process” (Rochlen et al., 2004, p. 271). Moreover, therapists have
drawn parallels between cyber counseling and journaling, noting
similarity in the catharsis that occurs due to writing one’s feelings
but different as cyber communication is
a conversation between two people so it was more interactive than
journaling… instead of just writing into a journal where no one
would see it, it’s like now someone is reading this and responding in
a way that’s really good
(Mishna et al., 2015, p. 174). Finally, cyber communication may help
patients who experience dissociation as a result of attachment trauma
to reflect on fragmented self-states and “stand in the spaces” (Bromberg, 1998), a process that can be experienced as dangerous and
inaccessible during face-to-face therapeutic interactions.
Text-based technology such as texting and e-mail are distinct
from the use of telepsychology or video-therapy in that they allow
private reflection similar to journaling, yet with a stronger connection to the therapeutic relationship. In this they are perhaps
comparable with the use of the telephone in therapy. The use of the
telephone has long been accepted for administrative aspects of
psychoanalysis such as scheduling appointments (Bhuvaneswar &
Gutheil, 2008). Similar to ICT, discussions regarding telephone
use in analysis have identified the loss of nonverbal communication when teleanalysis is a consistent substitute for face-to-face
therapy (Scharff, 2012). Yet the use of the telephone has been
argued to be at least comparable if not superior to face-to-face
treatment, with the potential to enhance and intensify such processes as client self-discovery and empathic listening by the therapist (Aronson, 2000). The clear and thoughtful use of the telephone as an addition to the therapeutic process in dialectical
behavior therapy (DBT) hints at the potential for text-based technology use alongside face-to-face therapy (Bhuvaneswar &
Gutheil, 2008). Despite the similarities, there are important differences. The use of the telephone in DBT has very clear parameters,
and allows therapists to regulate time frames and therefore establish boundaries on its use (Bhuvaneswar & Gutheil, 2008). As
discussed in the case illustration, for patients like Donna, with
whom the therapist is looking to increase security and decrease
anxiety, text-based technology may allow greater flexibility for
personal reflection. While expectations can still be established
regarding the responses by the therapist, as was the case with
Donna, e-mails can be written whenever and wherever the patient
feels safe; there are social conventions however, regarding when
one can telephone someone (Gabbard, 2001). The perception of
connection while simultaneously having unstructured time and
privacy to write and reflect in text-based cyber communication
may create the opportunity for potential space, unencumbered by
the destabilizing aspects of face-to-face or even telephone interactions, which can be difficult for patients with attachment insecurity (Whitty & Carr, 2006; Winnicott, 2005). This is similar to
the use of the telephone as a transition space described by Aronson, whose “patient could not tolerate the usual comings and
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
92 RINGEL, MISHNA, AND SANDERS
goings of the treatment situation, which impose an experience of
separateness” (Aronson, 2000, p. 147). When reflecting on Donna’s treatment, it seems clear that e-mail communication provided
her with a potential space that allowed greater reflexivity protected
from the therapist’s (S.R.) presence and potential intrusion. At the
same time, it may have been a challenge for Donna due to her
intense need for immediate responsiveness and her deep fear of
abandonment. Having to wait for the therapist’s response within
the structure of twice weekly sessions, however, seemed to help
regulate Donna’s anxiety and help develop her capacity to be alone
(in the virtual presence of the other).
Text-based ICT may create greater safety, as the sensory and
affective signals a patient like Donna craves may also increase the
patient’s anxiety regarding intimacy with the therapist. The use of
e-mail can create “a self preservation barrier to intimacy” (Gabbard, 2001, p. 726). Donna’s e-mail, cut and pasted from Wikipedia, may have been a tentative test of the process, a way to gauge
the therapist’s reaction without yet risking vulnerability of putting
herself directly within the dialogue. The ultimate goal is to bring
more of the patient’s authentic self into the therapy, and for Donna
this began by using e-mail to create a safe space, which then
allowed a more spontaneous self-expression, promoted deeper
reflection, and led to her recognition of dissociative triggers that
could then be addressed in face-to-face therapy.
For some patients, online communication may also have the potential to dilute the intersubjective aspects of the therapeutic process,
however, thereby creating a disembodied dimension that lacks the
immediacy and intensity of face-to-face engagement. As noted, the
option for online communication may inadvertently create enactments
that may be difficult to identify and process, because of the lack of
sensory and affective signals during patient–therapist interactions.
With patients like Donna, who desperately need the visceral, sensory
level of bodily and affective connection to feel loved and held, online
engagement may be experienced as too removed and abstract. Such
considerations are in-line with those identified by Barth when striving
for balance between separation and connection in the use of the
telephone in psychoanalysis (Aronson, 2000). Additionally, for those
patients who exhibit borderline pathology, the potential for unfettered
access to the therapist may serve to erode the time tested therapeutic
boundaries that are reinforced through scheduled sessions (Bhuvaneswar & Gutheil, 2008). Actual or perceived access to the therapist outside of structured and scheduled appointment times may prove
too difficult to manage. As it is very early on in the use of text-based
cyber technology in therapeutic settings it is premature to identify or
generalize to specific populations with whom it may be most effective.
Informal text-based technology as an adjunct to face-to-face
therapy should be introduced in a thoughtful way, considering the
implications for the client in relation to the therapeutic relationship
(Peterson & Beck, 2003). Expectations regarding therapist response to communication should be made explicit and these should
consider the implications for transference and countertransference
when clients become privy to daily routines of therapists outside of
session times through the additional information that often comes
with technology based communication, such as the time an e-mail
is sent (Bhuvaneswar & Gutheil, 2008). Additionally, it is argued
that all forms of extra communication be brought into the context
of face-to-face therapy and become part of the psychoanalytic
process (Gabbard, 2001).
Of course, the discussion should include the therapist’s own
self-interest and self-care as well as their motivations in making
use of informal cyber communication. In working with patients
like Donna, the therapist must be mindful of his or her emotional
survival, personal limits, and need for self-preservation, as well as
the requirement for a reflective space of their own from which to
formulate and conduct the treatment (Slochower, 1996).
In the scant literature on the informal use of information and
communication technology, there is a focus is on the risks and
need for guidelines and standards of practice. Literature is required
to examine how information and communication technology can
informally supplement face-to-face practice in a beneficial and
ethical manner that furthers the therapeutic process and contributes
knowledge for analytic practice. To achieve this goal, it will be
essential to obtain not only clinicians’ perspectives, but patients’
perspectives as well (Mishna et al., 2015). A study conducted by
Mishna and colleagues (2015) found that for the clients, who were
undergraduate students, cyber was an extension of the relationship,
as they felt the therapist was there for them somewhere in the
cyber world “most anytime.” Because they envisioned their therapist as continually available through the cyber medium, their
sense of connection with the therapist was extended. The undergraduate student clients’ experience of a “holding environment”
(Winnicott, 1971) was strengthened by rereading what their therapists wrote to them, whenever they wished (Mishna et al., 2015,
p. 178).
While the focus of this article is text-based online communication, the challenges and opportunities of online communication in treatment, and its potential to provide a reflective
space for certain patients, it is important to note that other
adjunctive treatment modes include letter writing, phone communication, texting, and messaging, as well as video-based
treatment such as Skype and Face Time. These options have
become quite pervasive and have created both old and new
possibilities to augment in-person treatment. The growing literature on information and communication technology in therapy requires further theoretical, practical, and technical elaboration to identify the benefits and address a range of complex
issues (see Aronson, 2000; Essig, 2012; Scharff, 2012), as well
as more extensive research.
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• When assigning your order, we match the paper’s discipline with the writer’s field/specialization. Since all our writers are graduates, we match the paper’s subject with the field the writer studied. For instance, if it’s a nursing paper, only a nursing graduate and writer will handle it. Furthermore, all our writers have academic writing experience and top-notch research skills.
• We have a quality assurance that reviews the paper before it gets to you. As such, we ensure that you get a paper that meets the required standard and will most definitely make the grade.

In the event that you don’t like your paper:

• The writer will revise the paper up to your pleasing. You have unlimited revisions. You simply need to highlight what specifically you don’t like about the paper, and the writer will make the amendments. The paper will be revised until you are satisfied. Revisions are free of charge
• We will have a different writer write the paper from scratch.
• Last resort, if the above does not work, we will refund your money.

Will the professor find out I didn’t write the paper myself?

Not at all. All papers are written from scratch. There is no way your tutor or instructor will realize that you did not write the paper yourself. In fact, we recommend using our assignment help services for consistent results.

What if the paper is plagiarized?

We check all papers for plagiarism before we submit them. We use powerful plagiarism checking software such as SafeAssign, LopesWrite, and Turnitin. We also upload the plagiarism report so that you can review it. We understand that plagiarism is academic suicide. We would not take the risk of submitting plagiarized work and jeopardize your academic journey. Furthermore, we do not sell or use prewritten papers, and each paper is written from scratch.

When will I get my paper?

You determine when you get the paper by setting the deadline when placing the order. All papers are delivered within the deadline. We are well aware that we operate in a time-sensitive industry. As such, we have laid out strategies to ensure that the client receives the paper on time and they never miss the deadline. We understand that papers that are submitted late have some points deducted. We do not want you to miss any points due to late submission. We work on beating deadlines by huge margins in order to ensure that you have ample time to review the paper before you submit it.

Will anyone find out that I used your services?

We have a privacy and confidentiality policy that guides our work. We NEVER share any customer information with third parties. Noone will ever know that you used our assignment help services. It’s only between you and us. We are bound by our policies to protect the customer’s identity and information. All your information, such as your names, phone number, email, order information, and so on, are protected. We have robust security systems that ensure that your data is protected. Hacking our systems is close to impossible, and it has never happened.

How our Assignment Help Service Works

1. Place an order

You fill all the paper instructions in the order form. Make sure you include all the helpful materials so that our academic writers can deliver the perfect paper. It will also help to eliminate unnecessary revisions.

2. Pay for the order

Proceed to pay for the paper so that it can be assigned to one of our expert academic writers. The paper subject is matched with the writer’s area of specialization.

3. Track the progress

You communicate with the writer and know about the progress of the paper. The client can ask the writer for drafts of the paper. The client can upload extra material and include additional instructions from the lecturer. Receive a paper.

4. Download the paper

The paper is sent to your email and uploaded to your personal account. You also get a plagiarism report attached to your paper.

GET A PERFECT SCORE!!!

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