In The Distance Cure, author Hannah Zeavin considers remote therapy’s potential for health equity and “distanced intimacy.” Using a creative (and unorthodox) definition of teletherapy, she traces its growth from Freud’s correspondence with a father whose child had a horse phobia and World War II radio broadcasts from British psychoanalysts to 1970s radio therapists, the growth of suicide hotlines and today’s Zoom therapy and mental health apps.
Was the world of psychotherapy transformed by the advent of the coronavirus pandemic? That’s an easy “yes.” With office visits all but impossible, those on both sides of the therapeutic equation—clinicians and patients—scrambled to adapt to other means of communication. Has the transformation been positive? That answer would have to be more nuanced. The widespread move to screen-based alternatives like Zoom has offered increased flexibility, greater outreach, lower costs, and broader access, among other advantages. But many have also mourned the loss of the immediacy and intimacy associated with in-person therapy.
This shift’s implications for the delivery of mental health care are still being digested and debated. Given this context, The Distance Cure: A History of Teletherapy, offers a timely and illuminating reminder that psychotherapy, when broadly understood, has long involved therapeutic interactions over distance. For the book’s purposes, the understanding of “teletherapy” encompasses not just live Zoom sessions but various print, broadcast and online approaches, including automated ones, for disseminating mental health guidance and care.
The author, Hannah Zeavin, is a lecturer in English and history at the University of California, Berkeley, and is affiliated with the Center for Science, Technology, Medicine and Society. As Zeavin explains near the outset: “Teletherapy, like telemedicine, is a catch-all term to describe a therapeutic intervention over distance, now most frequently accessed over the computer and mobile phones in order to go where traditional therapy can’t: to locations where no specialists are available, to the institutionalized or homebound, to vulnerable or at-risk populations, to patients with different linguistic needs.”
Most of The Distance Cure was apparently written before the pandemic; a coda, dated June, 2020, briefly addresses the coronavirus-related Zoom boom. (Zeavin further examined this issue last year in a bracing commentary in The Guardian.) In the book, Zeavin starts by rebutting the perspective that the standard, dyadic therapeutic encounter—that is, a licensed expert and a patient meeting in an office at a predesignated time—creates a venue for unmediated or “pure” communication. That perspective obscures a more complicated reality, she argues.
In her formulation, the interactions and relationships that characterize in-person talk-therapy are themselves “mediated” through an established structure of rules and customs. Positing that the “frame,” setting or medium of communication is always a third element in the dynamic, she reconceives the therapeutic relationship as a triad. This triad, she suggests, “provides a unique site for examining these current concerns about what media add to human relationships and what they subtract.”
Zeavin’s focus is largely on what media can add. Her historical analysis begins with Freud and the establishment in the 1890s of a prescribed system of providing psychodynamic treatment for mental health problems. This approach called for a long-term program of fixed appointments for one-to-one interactions between psychoanalyst and patient—the forerunner of today’s multi-session talk therapy model. But even Freud, notes Zeavin, departed from this standard arrangement when he engaged in a correspondence-based analysis of a five-year-old boy who refused to leave his home for fear of being bitten by a horse. Freud conducted this treatment through an exchange of letters with the father of the boy, nicknamed Little Hans, and later published the account. “As with subsequent forms of teletherapy, Freud’s epistolary analysis dissolves the walls of the consulting rooms to allow access to help that one does not have to leave the confines of the home to receive,” notes Zeavin. (Interestingly, Freud also broadcast a short, defiant talk about psychoanalysis on the BBC in 1938 from his home in London, just a year before his death as the city prepared to German air raids.)
Zeavin covers how some prominent British psychoanalysts, including Susan Isaacs and Donald Winnicott, later used mass media, including magazine advice columns and radio broadcasts, to disseminate mental health advice during periods of collective suffering like the depression and World War II. She investigates the growth of suicide hotlines, starting from the efforts of Chad Varah, a British Anglican vicar who launched the first such service in 1953. She analyzes the popularity of a spate of call-in radio shows hosted in the 1970s to 1990s by female therapists, including Laura Schlessinger, a conservative moralist known for her anti-feminist opinions on marriage and child-rearing.
In a section on computerized therapeutic interventions, Zeavin also describes how electronic platforms designed to mimic human responses have reconfigured the triad of patient, therapist and medium into an actual dyad—but with only one live participant. In all cases, Zeavin investigates the opportunities presented by these evolving therapeutic forms, including the unique ways they allow for the creation of what she calls “distanced intimacy.”
A key lesson of the book is that people seek and find connection in all sorts of ways, often enabled by distance. For some, meeting in person with a therapist is a scary and unnerving prospect, for any number of practical, social or psychological reasons. In such cases, the separation and possible anonymity afforded by e-mail and other online platforms might generate a sense of safety that makes it easier for many people to reach out for help. Zeavin documents this phenomenon with excerpts from the exchanges between an online therapist and a woman who felt much more comfortable conversing asynchronously through her computer than in real time over the telephone or other media. Notes Zeavin, “Therapy, or any spoken interaction, had an inhibition effect [on her]; moved online, the written version of the interaction was potentially a lifesaver.”
This brief example from the experience and words of an actual therapy recipient is heartfelt and moving. It enlivens the narrative and sticks in the memory, given the book’s largely theoretical orientation and the overall shortage of testimony from those on the receiving end of therapeutic engagements. I would have enjoyed learning more about the impact of the interactions on patients and consumers. For example, we do not hear much from people who’ve called suicide prevention hotlines or peer-to-peer counseling services. How was the experience for them? What about some examples of specific questions from Laura Schlessinger’s callers, along with her scathing, funny, and infuriating responses, or from callers to other shows? When it comes to teletherapy and teletherapies overall, are they effective? Do recipients find relief when the exchanges are mediated by telephone or radio or, more recently, online settings?
Many of these omissions may be due to the absence of archival data on individual cases or limitations on the use of such information, as Zeavin notes when she explains her research methodology. Whatever the reasons, the near-absence of this kind of detailed, first-person testimony from past or present teletherapy users felt palpable.
But The Distance Cure isn’t really that kind of book. It is concerned less with assessing personal outcomes than with mounting a spirited challenge to the normative, dyadic view of a therapeutic encounter and examining the processes, meanings and unexplored attributes of teletherapies. And let’s be frank—the book is not exactly an easy read. The prose can be difficult to plow through for those not versed in social science dialects. Readers can be forgiven, for example, for having trouble parsing statements like this: “The elements of the therapeutic triad…are not parallel forms of a clinical relationality but intersecting features of relationality and technique that can destabilize one another.”
Well, never mind – this is an academic book, after all. Zeavin nonetheless clearly conveys how teletherapy can serve a “democratizing function” and make therapeutic insights available to more people, especially those who would not be able to afford or access them—the disadvantaged, rural populations, low-income youth, the homebound and people for whom the stigma of mental illness has kept them away from traditional therapy.
“Teletherapy exists largely because in-patient therapy is excruciatingly expensive for almost all people, including many people who still manage to undertake it,” she writes. At the same time, she warns of the corporate and technological impetus to standardize and market digitized therapies, along with the resulting dangers: “
“Teletherapy exists largely because in-patient therapy is excruciatingly expensive for almost all people, including many people who still manage to undertake it,” she writes. At the same time, she warns of the corporate and technological impetus to standardize and market digitized therapies, along with the resulting dangers: “Big Tech’ corporations and start-ups that make use of algorithmic treatment of patients and clients expose those users to all kinds of vulnerabilities, biases and mistreatment, furthering inequalities.”
Bottom line: If you are an academic in the history of medicine and psychotherapy, or an expert in media studies and the dissemination of health information, or a scholar in the discipline of science and technology studies, this book is definitely for you. Those wanting to hear in-depth stories from patients and therapists about how they have fared in the current Zoom moment will have to wait.
–David Tuller, DrPH, a journalist who has written for Health Affairs and The New York Times, is a senior fellow in public health and journalism at UC Berkeley’s Center for Global Public Health.