Protective Distance

Letters always, according to Lacan, reach their destination. We all write with others, even or especially when we sit down to make work that is classified as a monograph, a site of supposedly individual effort.  What a particular honor then, to have the letter that is my book, The Distance Cure: A History of Teletherapy, considered alongside the work of one of its intended addressees. Jeremy Greene’s The Doctor Who Wasn’t There, as it was being written, shaped my own work immensely; for a group of colleagues, whose own scholarship is signal, to read them in tandem is a great honor and deeply appropriate to how The Distance Cure was formed on the page.

How the books have been necessarily received is a different matter: I think neither Jeremy nor I could have ever predicted that these two letters, monographs on care at a distance, would become quite as timely as they did during the COVID-19 pandemic. If, as I wrote in the book, teletherapy was therapy’s shadow form, and needed to be reckoned with as such, Jeremy and I both revised books written before the COVD-19 pandemic in a moment where tele-care made its latest and greatest debut, to the most people, and all at once. Our historical hypotheses were suddenly put to the test as these understudied forms of care were often the only care on offer. The comradery I felt with Jeremy in writing and revising our books will be, I am sure, one of the great experiences of my intellectual life.

Over the course of their long history, telemedicine and teletherapy have frequently been framed for their democratizing promise: they can go where traditional medicine can’t or won’t. Whether in the Alaskan wilderness or East Harlem housing projects (in The Doctor Who Wasn’t There) or an asylum in Blida, Alegria or a basement office in San Francisco’s Tenderloin, tele-care technologies were oft proposed as technologies of equity, leveling the vast disparities in access to care. While Jeremy centrally looks at the U.S. case, and how this has largely characterized the American healthcare system across the 20th century, consolidating in the Post-War era, I trace this form of care as a technique that emerged in Freud’s office and traveled quite widely.

The central contention of the Distance Cure is that, contrary to the notion that teletherapy (or therapeutic interaction over distance) is a new, app-derived practice, teletherapy is at least as old as psychoanalysis itself—Freud made use of the form for his own treatment and that of others. Beyond fin de siècle Vienna, the relationship between therapist and patient has long been mediated by communication technologies (e.g., the earliest mainframe computers, pre-internet networked computing, and now mobile phones). In The Distance Cure, I track the history of teletherapy and its metamorphosis from a model of cure to one of contingent help (and, in the pandemic, back again). I describe its initial use in ongoing care, its role in crisis intervention and symptom management, and our pandemic-mandated reliance on regular Zoom sessions. My account of the “distanced intimacy” of the therapeutic relationship offers a rejoinder to the notion that contact across distance (or screens) is always less useful, or useless, to the person seeking therapeutic treatment or connection. Instead, the book argues that the history of the conventional therapeutic scenario cannot be told in isolation from teletherapy—that in-person care and distant treatment have long informed each other.

What struck me in several of the replies was the dual focus on archives and on politics, and often how they interrelate. Hicks and Grimaldi both highlight the nature of the archives upon which our books were evidentiarily formulated. About my book, there seems an ambivalence (in, aptly, the Freudian sense) about there being too much and too little; I shared it. The kinds of records and data of much of teletherapy are incomplete yet overly revealing. Whether the partial record of Freud’s own distance analysis with Wilhelm Fliess (the former of whom burned the latter’s letters) or the impossibility of fully accounting for the listener’s experience of Winnicott’s radio shows (despite some extant fan letters), from the terribly detailed notes of suicide call logs and messages to the self-case study of an early e-therapy patient, all of the material I worked with was both highly private (and therapeutic, even in its failures) and necessarily incomplete. As Grimaldi notes, it is often exactly the historian’s job to “work tirelessly to close historical distance”; and yet in our books, distance is not just the object of study but also a formal, and perhaps as Grimaldi proposes, generative limit.

As Guenther notes, both books are about the politics of care, and thus political in themselves. Greene and I each resurface forms of care that were filled with hope for care—even as those hopes were often dashed. By creating a rolodex of bygone models of care (and those that were activist and have now become commonplace and state-directed, like the suicide hotline), Guenther, like Ostherr and Virdi, hopes that via accounting for the contingent failures of these forms of care, we might be able to better reckon with the onslaught of new forms of techno-care and the co-opting of older mediated forms with an eye to structural inequality and access. As letters that document the past—including the very recent past—they can be read in light of our now. I hope that Jeremy and my books together offer just the beginning of empirical, historical studies of how mediated medicine and mediated therapy have traveled, been made use of, and been torn down.

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