Reconsiderations on Online Psychoanalysis

by Silvestro Lo Cascio

Key Words: Online psychoanalysis – E-therapy – skype-therapy – setting – online psychotherapy

Abstract: this work explores, without any theoretical prejudice, the use of new information technologies within the analytical setting. An examination is carried out on the strengths and weaknesses that the use of these tools could bring to the therapeutic relationship. The effects that could fall on the setting, on the transference and on the interpretation are looked at with critical lenses. Furthermore, in order to clear the field of risky confusion of languages, the distinction between “analysis” intended as standard psychoanalytic treatment, and psychoanalytic therapeutic intervention, instead characterized by a character of brevity, is underlined. The session via skype can be understood then, not as a psychoanalysis, but as a psychoanalytic therapeutic intervention, where according to certain circumstances, such as a temporary transfer of the patient, a hospital stay, or as in the most recent case of a pandemic, online psychoanalysis would contribute to the opportunity for the patient to start again.
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Premise.

Before starting to penetrate the thorny issue of online psychoanalysis it is good to highlight some considerations; among whichare digital natives readers born after 1985. All native speakers of the computer language, grown with on presence of the Internet with video games and social networks, have always communicated spontaneously and naturally through mobile telephony, text messages, e-mails, instant messaging up to VOIP calls. However digital migrant, or people aforementioned date, this category with the advent of digital, have witnessed radical changes that have affected the world of work, communications, interpersonal relationships, and even if they have learned the new digital language, they have not completely lost the accent of their language of origin, expressing the perplexities concerning the massive use of digital technologies that has invested every field, from medicine to the human sciences ( Prensky 2001, 2010). It should also be stressed that we find ourselves in an irreversible process of digital empowerment that involves every human activity, especially cognitive ones. Needless to say, digital technology has changed some of the dynamics of interpersonal relationships, to the point that we talk about Iphone effects to describe how in communication contexts within groups, the mere presence of the mobile device, starts to divertte attention of the interlocutors, who lose interest in the discussion wile checking their smartphone (Misra et al., 2014). Smartphone that wed now use as a personal computer, clock, map, television, and as a telephone, have affect both the behavior and the emotional sphere (Carr 2011). Unlike the old media, in which television represented the instrument that had altered the interpersonal relationships face to face (Ong 1982), his characterized by interactivity, burst into relationships and are always turned to the eye and to control the Other. But the dynamics that are created in the interaction via the Internet, such as video chats, inspired by a work by Metz (1980), in some respects could paradoxically be closer to those of the theater than to those of the cinema. In fact, in the play, actor and spectator are present at the same time and in the same place at the same time, even if in the case of the internet it is present at the same time but in different places, while at the cinema the actor is present when the viewer is absent and vice versa, moreover the voyeurism of video chats, is more similar to that of theater, resting also on an institutionalized fiction and justified in the order of reality, where the object agrees to be seen, a little as happens in the theater or in striptease shows, but also on the internet a voyeurism similar to the cinematographic one develops, where the consensus of the spied object is missing, in these cases, the user who goes to check a profile of the other, looking at all the photos, the movements, the interests, or the user who goes to spy on the videos posted live on Facebook, or even the user who spends days watching pornographic sites, could be represented as spectators in the dark hall of a cinema watching something that lets itself be seen without being seen (Metz 1980).

The user can therefore be in an office, in the kitchen of his home, and at the same time can see without being seen, an act that lacks that conscience which consists instead of seeing each other, where the gaze is always realized and in any case in the look of the Other (Lacan 1975). Internet like cinema has something erotic: shots, progressive revelations, bodies that show themselves in the balance with a censorship that simultaneously increases the excitement preventing it, obviously on the internet the censorship is absent and points only to an excitement without impediment, and where the naked bursts without modesty, but both can be compared to a form of partial object relation that facilitates aspects of perversion fueled by fetishism, and where in both cases, the properly fetishist element becomes the limit of the screen, the stop looking with regard to the cinema and the arrest of physical contact with regard to the internet; perhaps it is a gamble to dare to say that the Internet goes to occupy the position of a bad object that once occupied the cinema, putting itself in the position of being persecuted annihilated and destroyed, and later studied as a form of reparation (Metz 1980). But despite the virtual relationship through the screen is excludes and becomes paradoxically omnipresent and always subjected to theatrical forms of extimitè (Lacan 1959-1960), just observe the various profiles that are created on social networks, to realize how this body parceled out and cut by endless photographic shots is exposed as a visiting card to remind the world of its existence and to show an almost obsessive physical perfection (Ferraris and Malavasi, 2001), and so the holidays become photographs of parts of legs, or feet, or bottom that have the sea in the background. Motherhood is represented with a naked bump photographed and shown, a dinner becomes the photograph of perfect hands holding a glass, and so on, images however that are reinforced by objects itself in the form of Like; also the dynamics that are created on the internet show that the relationship with partial objects is not limited to childhood alone (Eagle 2012). The new digital technologies, place us in a continuous “presence absence”, comparable to a mind-body split, created by the continuous use of mobile technologies with Wi-Fi connectivity, where, physically present, we are instead projected, through the technological tool, always elsewhere (Gergen 2002). On the subway, in public offices, each individual is connected to his digital device, and most of the time, not to talk, but to check notifications, play, listen to music, or simply make sure of On-line or off-line status of the Other.While we write to our PC, at the same time we check the e-mails, we look at the news, we look for the cheapest flight, we make payments, and maybe during all these operations, our perception, distracted by a fictitious vibration, forces us to control the smartphone to read or hope in the arrival of a message or a call, so we find ourselves simultaneously occurring in multiple and parallel activities in a state of called cyber-based overload (Misra & Stokols, 2012a). Within a few years, without realizing it, we have become the citizens of a cyber-culture, witnesses of a global process of mental change, which has modified as written a little, not only our way of thinking and our cognitive abilities, but also our style of life (Greenfield 2016). However this is not a new story at all, the transformation processes, linked to forms of communication, have always made changes in the ways of thinking, and have given rise to resistance or hope, when one is passed from the orality to writing, we witnessed a textual prejudice (Havelock 1986), to the point that Plato came to define writing, as inhumane and harmful to memory (Ong 1982). Instead, Montaigne considered the press as a literal innovation, where his obscenity, in expanding, could become explicitly didactic. At that time the new technological cliché was represented by the newspaper, to the point that Lamartine argued in 1830 interest in the new medium, noting the innovative and immediate way of communicating, describing the everyday as a new technology, able to create a link between the public and the writer every twenty-four hours, whereas the book took weeks and months to establish the same relationship (Mclhuan 1962). The present work does not intend to take clear positions, or to stand in favor of or against the phenomenon, but hopes for a question, through the extra-individual singularity and nuances, the nuance (Barthes 1964) that distinguishes itself from the general and pre-established positions, and where every case should always be seen as unique.

Terminology used.

With the rapid spread of the use of information technology in the field of mental health, there has also been a proliferation of terms to indicate the various ways of performing health services through the Internet. In this regard, in order to put the banks to an unstoppable terminology babel in which one could easily disorient, several scholars (Perle 2011; Nickelson 1998; Rochlen et al., 2004; Barak et al., 2009; Dielman et al., 2010) attempted to provide a universal nomenclature to the scientific community. The following are some terminologies concerning the psychology services provided through technological tools, contained in the Ohio Psychological Association guidelines (2008):

Tele-health: term used in the field of medicine and psychology, which consists in the dissemination of information through image or voice files, through telecommunications means to provide consulting services, education, clinical training, diagnosis, evaluations, and hypotheses of treatment.

Telepsychology: are all those psychological services, such as consultancy or didactic training, provided through means of distance communication, such as telephone, chat, e-mail, videoconferences, etc.

Online therapy: any type of therapeutic interaction between patient and professional, carried out via the Internet or by telephone, in this mode do not belong consultation and training activities.

E-Therapy: this term means a psychotherapy carried out through the Internet, in which the patient and the psychotherapist interact via chat or via Skype.

e-therapy: means communication and interaction over time between patient and therapist, during periods that may be physically distant from each other, through e-mail, chat or even skype.

Web-based interventions: are self-guided web programs, which have as main objectives, information, prevention and above all to make positive changes to lifestyles, users can receive information ranging from food to medicine, to sports, drugs, mental health, surgery etc … these programs are characterized by self-guided interventions, where users do not establish a direct relationship with the professional.

Online counseling: are those services provided by the network, where the customer by connecting to the website that deals with the specific issue, can contact a professional, through e-mail, forum, chat rooms, skype, to ask for psychological consultations, or ask to be directed by a therapist to undertake a therapy.

Internet-operate therapeutic softwar: they are artificial intelligence programs that use a three-dimensional technology, for example they can include games, virtual environments, and are used as support for cognitive or even motor rehabilitative therapies.

All these activities use different channels of communication: asynchronous, in which the information exchange does not necessarily take place simultaneously, so this category includes text messages, e-mails, blogs, forums, audio and video recordings; synchronous, in which the communication between client and therapist occurs in real time through telephone, video or text-driven chat, instant messaging, etc ..; it can be communicated in textual or multi-sensorial form; in imaginary form using programs such as MOOs or MUDs (Merciai 2002); but all these ways of communicating, like any symbolic system, can also represent a powerful means of organizing emotions (Lurila 1932) on the web, as well as in the various forms of art.

Online psychoanalysis.

On-line psychoanalysis, E-therapy, or skype-therapy, now a reality widespread in psychoanalytic environments, is arousing curiosity and indignation, but if we go to look for a psychoanalyst through the internet, it can very well be noted that most of then, besides having a facebook profile, own a personal blog, share articles, post, make public her curriculum vitae and the school of belonging. In addition, under the heading contacts, in addition to the phone number, now strictly mobile, address of the study with google maps attached and e-mail, and almost all put the skype contact for any sessions via the internet. Online psychoanalysis, although it has become a reality all over the world, still moves between the non-unsaid of those who practice it, where for fear of being taken for charlatans, or for fear of being accused of betraying the scheme Orthodox of reference, one does but does not say (Merciai 2002). Online psychoanalysis has its roots in the United States since the nineties, the first to use the term e-therapy was John Grohol, providing free online psychological help and creating a website to help people with depressive disorders, in a very short time, has gone from the use of the telephone, then the teleanalysis, to e-mails, to chats, to videoconferences, up to the sessions via Skype (Perle et al., 2011). Obviously, since psychoanalysis is not regulated by a professional order, to practice on-line sessions, we adhere to the directives of the relative Orders of Psychologists or Orders of the Doctors of belonging. The art. 78 of the Code of Medical Deontology, updated to 2016, in which the “information technology and health innovation” session refers to information technology:

<< The doctor, in the use of IT tools, guarantees the acquisition of consent, the protection of confidentiality, the relevance of the data collected and, as far as it is concerned, the safety of the techniques. The doctor, in the use of information and communication technologies of clinical data, pursues the clinical appropriateness and adopts his decisions in respect of any multidisciplinary contributions, ensuring the conscious participation of the assisted person. The doctor, in the use of information and communication technologies for the purposes of prevention, diagnosis, treatment or clinical surveillance, or such as to affect human performance, adheres to the criteria of proportionality, appropriateness, efficacy and safety, in compliance of the rights of the person and of the application addresses attached >>.

Furthermore, in 2010, the Ministry of Health, in collaboration with the Sapienza University of Rome, drafted guidelines that only concern online communication on the subject of protection and health promotion. But back to the Psy area, where it is appropriate to highlight some aspects contained in the guidelines for psychological performance via the Internet and at a distance, pending a deontological codification in terms of Article. 41 of the code of ethics of Italian psychologists, which concern:

1. Security.

1.1 Identity of psychologists.

1.1.1 Psychologists must be recognizable so as to be able to verify their identity and domicile.

1.1.2 Associated psychologists who develop websites must facilitate their identification as sites belonging to psychologists registered with the professional association.

1.1.3 The single or associated psychologist who offers services via the Internet is obliged to report the web address of the site at which he / she provides such services to his / her professional association.

1.1.4 Psychologists are required to specify their registration with the Professional Order. If they also specify membership in scientific associations they must make these associations identifiable and reachable and the relevant statutes can be found.

1.1.5 Where a service is provided by multiple psychologists, this must be clearly specified. In any case, the author of the service must be identifiable.

1.1.6 If the professionals involved belong to different professional skills, these must be clearly identifiable. The website on which psychological services are offered must be provided with information on the professional standards and the code of ethics in force, and on the methods for consulting them.

1.2 Identification of users.

1.2.1 The identification of the user must normally be requested.

1.2.2 Even in cases where a given provision generally provides the possibility of guaranteeing the anonymity of the user, the psychologist must always evaluate the compatibility on a case-by-case basis. The guarantee of anonymity must always involve, on the part of the psychologist, the adoption of additional precautions, also in relation to the possibility that users can

need specific protection or have a specific legal status (for example a minor).

1.2.3 Psychologists who guarantee anonymous access to professional services must clearly specify which benefits are compatible with anonymity and which are not.

1.2.4 The professional services that guarantee anonymity are likewise subject to the rules on informed consent, even if they can only be acquired with an identifier of the client.

1.2.5 Distance professional services for minors or clients subject to protection require particular attention and greater security measures.

Particular attention should be paid to the authenticity of consent by those exercising parental responsibility or protection.

1. 3 Protection of the transaction.

1.3.1 Psychologists must ascertain the security of transactions, including financial transactions, and the confidentiality of psychological and personal information, including through the use of targeted technologies.

1.3.2 In any case, maximum security must be sought on the Internet site, on the telephone line or on other electronic means used, through suitable equipment (hardware and software) and including the use of encrypted services.

1.3.3 Security levels must always be updated.

2. Confidentiality.

2.1 Recognition of limits.

2.1.1 Psychologists must ensure that users are informed about the legislation concerning the protection of data on any type of media are recorded, the communication of information and limits on confidentiality, for example in cases where reporting or reporting is required.

2.1.2 Users should be informed about the data stored and their rights to them.

2.2 Storage of data.

2.2.1 The rules on data and information custody also apply to distance services for any type of media or technology being used.

2.2 Storage of data

2.2.2 Psychologists must take into account the possibility that interaction via telematic means may involve the recording and storage of information also by the user.

In 2013, the National Council of the Order of Psychologists drafted recommendations on psychological performance through distance communication technologies, where waiting for a broader and more significant scientific literature, it provides indications for those wishing to follow this practice. Notwithstanding that the ethical principles and rules of professional ethics of the psychologist also apply to the services that are carried out remotely, via the internet or by other means, the point of interest in our discussion is dealt with in Article 6 of the aforementioned recommendations of the CNOP, which are read the textual words << in the context of clinical activities (such as psychotherapy, psychodiagnosis …) the establishment of a direct relationship, in person, is an indispensable condition for any subsequent use of distance communication >>. So it is good to point out, immediately that a skype analisis can not be absolutely understood as an alternative model to the analytical setting, but can be used in certain situations as integrative support, in order to allow the continuation of a therapy, an analysis or supervision. As for example, in some cases in which a patient could find a change of city for work or study reasons. In fact, in the contemporary scenario there are more and more young “expats” who move away from their countries of origin, but also in cases where some patients may find themselves facing hospital stays to name a few. In the history of psychoanalysis there have always been cases that have generated discussions or resistance, since the IX International Congress held in Bad-Hombourg in Germany around the twenties, the resistance of European analysts to the psychoanalysis practiced by -medici (Bokanowsky 2000), and in 1926 Freud published a work entitled “the problem of analysis conducted by non-physicians” in which he already imagined a dialogue with a virtual interlocutor, a few years later, in 1928 Ferenczi publishes “the elasticity in psychoanalysis “, and famous is the letter that Freud sent to Ferenczi with which he criticized it for some issues such as” the technique of kissing “. It can very well be said that the history of psychoanalysis has an important contribution to the correspondence that Freud held with analysts such as, in addition to the aforementioned Ferenczi, with Jung, Fliess, Binswanger just to name a few, rich correspondence of transference, countertransference and other technical contents , as in the case in which Freud in a letter with Binswanger and Maeder, suggested for a patient characterized by compulsive onanism, the use of a urethral probe as a form of containment (Molaro 2016). In 1953 Eissler, to explain the changes in the classical setting, due to the influence of ego psychology, introduces the concept of “parameter” based on the following criteria: it must be introduced only when it can be proved that the basic technique is not sufficient; it must never exceed the inevitable minimum; must lead to its self-elimination; its consequences on the transference must not be such that it can not be abolished by interpretation. Eissler suggested using the parameters to the pact that were reduced to a minimum and that could be part of the process of interpretation (Migone 2003). Parameters that could be in line with what was maintained by Odgen (2009), according to which one must be able to reinvent psychoanalysis with each patient. A psychoanalysis that has been extended through changes to the setting and the analytical method, the vis a vis in alternative to the couch, the importance of the subjectivity of the therapist, the “Corrective emotional experience” (Alexander 1946), self-disclosure, the empathic relationship, but also a psychoanalysis that has crossed other contexts, such as: the institutions; the couples; parents and young children; just to name a few. A psychoanalysis, therefore, which has its own history, but which moves and goes on, in continuous germination would say Ferro, and where the analyst’s place is not always said to be his study, his corporeity or his sofa, but the the analyst’s place is what makes the analysis possible (Freites Giovannetti 2013). In this regard, psychoanalysts are not new to receive psychoanalytically unorthodox proposals and to leave their studies to make psychoanalysis possible, as when Adriano Olivetti, asked Cesare Musatti to undertake the analysis with him on terms that “during the holidays she follows me on my travels and gives me the analysis >> (press, 2016, Sara Ricotta Voza). Another example of psychoanalysis that comes out of the preconceived schemes is the remote analysis, a successful experiment carried out by the International Psychoanalytical Association (IPA), which sets as a priority that of helping psychoanalysis to stay alive, to help it having an authoritative role in the contemporary world and developing even in countries where it is not practiced, after so many resistance and prejudices, starting from 2002 founded the Psychoanalytic Institute for Easten Europe (PIEE), as the body responsible for analytical training and research in ‘area of ​​Eastern Europe, an institution that through the shuttle analysis or concetrated analysis, allows the many candidates for training, who do not have the opportunity to undergo a standard analysis because of their geographic isolation or other special circumstances, an adequate analytical preparation recognized by the IPA, the shuttle analysis or the concetrated analysis, consists of i n blocks of psychoanalysis sessions divided into annual periods of about eight weeks each, during which the candidates coming from these remote geographic areas of the East, move for these periods in the city of their analyst, where they have the possibility to sit a superior number of sessions compared to the traditional four weekly sessions; later another analysis method was also carried out concentrated in the first ten days of each month; furthermore, the innovative element introduced to meet the students is that between the pause periods of the shuttle, they can make sessions via Skype, both to continue the analysis and for the supervision, everything is regulated by the guidelines drawn up by the PIEE, from which we can deduce that as regards the analysis with skype, it can only be understood as a supplement, and can not at all replace the minimum number of 100 established sessions; as regards supervision, it is also permitted through skype, email, telephone or fax, provided that a certain number of face-to-face supervision is guaranteed (PIEE 2015, Fonda 2011, EPI 2002).

Effectiveness of online therapies.

Very few studies exist in the literature that demonstrate the efficacy of on-line psychotherapy, and moreover almost all of them are performed taking as a therapeutic model of reference, the cognitive behavioral model. Obviously this may be due to the fact that in cognitive behavioral therapies shorter changes can be observed, they are better suited to programs of guided autotherapies, and because, perhaps in line with a certain hypermodern thought that does not tolerate waiting, and would like everything immediately within a click. An important contribution is given by studies (Bitencourt Machado et al., 2016, Johansson et al., 2012), which analyzing two authoritative scientific databases, EMBASE and PsycINFO, a number of 570 studies, they selected 59, on the basis of some characteristics: studies concerning forms of psychotherapy carried out exclusively on-line with patients all over the age of 18; studies of online psychotherapies in combination with web-based interventions, in which the relationship with the therapist took place after the autotherapy sessions, using synchronous or even asynchronous communication channels such as e-mails. Instead, treatments carried out exclusively with self-therapy programs, such as Internet-operated therapeutic softwares, exclusively pharmacological treatments, and forms of psychotherapies associated with general health problems, such as parkinson’s, diabetes mellitus, brain traumas, cardiac problems, etc. have been excluded. The duration of the therapy was about 25 weeks for both groups, including the control group characterized by face to face psychotherapy; each study was evaluated by the authors of the research and discussed in groups, specifying the characteristics of the patients, the type of therapeutic approach, the characteristics of the on-line psychotherapy used, other characteristics of the therapies used both for the study group and for the group control, the main objectives and the main results. The main diagnoses of the related studies included post-traumatic stress disorder, generalized anxiety disorder, panic attacks, social phobia and major depressive disorders. A significant data emerged from all the selected studies concerns a reduced economic cost of treatment, the efficacy obtained from the form of combined therapy, while only two of the selected studies were performed with psychodynamic psychotherapy treatment, the first concerned a case of disorder of generalized anxiety, compared to cognitive behavioral treatment, and similar results for both treatments at 18 months of follw-up; the second, a case of depressive disorder, at 10 months of follow-up gave better results than a psychoeducation treatment (Johansson et al., 2012). Desirable would be a greater interest in research, so that issues of this kind are not left to fend for futile discussions or a priori positions.

Some considerations on online psychoanalysis.

The use of technology in psychoanalytic practice has brought the written word in the setting into what is referred to as the talking cure par excellence, in fact, a written communication is frequent between the patient and the therapist, where the mail remains the most used mode, but there is not aNY use of text messages or instant messaging for shorter communications, such as communicating a delay or asking for confirmation of a session, but in any case these forms of communication are now part of the setting, establishing, before the actual meeting, forms of transference, and in some cases, these forms of asynchronous communications, such as e-mails, in contrast with the dynamics of verbal and non-verbal communication, have also given rise to forms of erotic transference in the analytic dyad (Gabbard 2001); moreover, the use of computer technology, redefining the traditional areas of privacy and clinical anonymity, raises the question of professional boundaries, which can be divided into three areas: ethical problems, professional problems and clinical dilemmas, (Gabbard et al. 2011). Patient and therapist find themselves in an ever-expanding online dialogue, before arriving in therapy patients seek information on social media platforms, blogs that talk about mental health, access to forms of online counseling, and already come from the therapist with their olofrase on the relative disturbance (I am depressed, I am anxious, etc.), the same applies to therapists who use these web platforms to share knowledge, but also to reach potential patients (Lifchez et al., 2012). These forms of interaction, while raising the problem of proper professional conduct, are not yet supported by a policy that deals with regulating the professional conduct of doctors in the digital area (Farnan J et al., 2013). It is evident that the web can influence the patient therapist relationship. Let’s put the case that a patient, before contacting the professional for a therapy, starts to consult the web, checking the personal page of the therapist to see the orientation and the curriculum. But in addition to consulting the personal page, another habit is to go to check the profile on the social networks of the therapist, in this case, the avatar of the therapist could also play an important role, influencing the choice of the patient. But this is only one side of the same coin, in fact on the other side, even the therapist can be moved by a curiosity, and before meeting the patient could perhaps go to check the profile of the social network to give a face to the person who must meet. All of this could help create an idea about the patient’s interests in the clinician’s mind. And even in this case, the avatar could condition the therapist’s attitudes. Our concern is that before arriving in session, we can create a sort of “preliminary computer” that triggers positive or negative mechanisms in the patient dyad. The various forms of communication, texting or voip, which also intervene intrusively between the patient and the therapist, raise the question whether or not to insert these forms of technological communication within the psychotherapeutic technique. Assuming that there is no a priori correct way of doing therapy, that every patient is unique, that psychotherapy is not coercive, that every patient should be allowed to show himself for what he is, and that we must in any case try to analyze what the patient chooses to communicate (Gabbard 2001, 2011, 2012), significant cases remain described by Gabbard himself to make better the idea of ​​some dynamics that could be created in the patient therapist relationship through the use of a technological communication . One for example that of a patient with borderline personality disorder and suicidal ideation, in pharmacological and psychotherapeutic treatment, who writes an email to the psychiatrist to ask how many clonazepam can be taken in a day because he can no longer sleep, emphasizing the urgency of the case; the therapist replies to this email, writing that he can not make changes to the treatment until they are seen, then invites him to call in the studio to schedule an appointment; at this point the patient writes a further email in which he communicates to the therapist that if he does nothing, he will be forced to take information from the internet about the drug, because he has immediate need to be able to sleep. In the other case described, Gabbard reports some instant messages that a patient sends him, for example before a session he timely communicates that he delays ten minutes because of traffic, the moment he finds the parking lot and even communicates when he arrives in the hall. waiting, or before entering the cinema, he writes a message to ask the therapist which actor would choose between two who lists them, etc …;

Considerations on the setting.

The hope of a psychoanalysis as a cure for the future, for becoming, for a psychoanalysis that goes on and produces new branches and new leaves. A psychoanalysis capable of really opening up to new settings, as Ferro would perhaps say, raises questions from which we can not avoid or pretend that nothing is done for the sole reason of avoiding anguish caused by the changes imposed by time. It is therefore appropriate to put aside some prejudices and start to see what a skype session is about it could change in the analytical setting. But let us go by order, and it is therefore appropriate, to make a distinction between “analysis” understood as standard psychoanalytic care, and “psychoanalytic therapeutic intervention” characterized instead by a brevity, where the listening and attention of the analyst, highlighted among other things in an interesting debate organized by the Italian Psychoanalytic Society, on the extension of the clinical method (De Vita 2016). Following this hypothesis for the present reflection, the session via Skype could be understood as a psychoanalytic therapeutic intervention, where according to the many circumstances described above, also through the use of this technology, to put it in Lacanian terms, psychoanalysis and in this In the case of skype, it would also help to give the patient the opportunity to start again. So we try to dissect what could change in the setting with the use in the analytical session of the technological tool, or if we can talk about an analytical setting. We therefore consider that a patient, for reasons of work, must move abroad, but does not intend to interrupt the sessions, or even other cases in which, using a Winnicottian term, “psychoanalytically ceasing to be psychoanalysts” is needed, and one opts for a sitting online. The main concern may be that a virtual setting can undermine that vision of setting as a “safe environment”, we have no answers in this and we can not have them, but our purpose is not to seek certainties at any cost. Instead, we should strive, even in such situations, to have more “negative capacity” to accommodate something new, wild (Bion1977-1983), where each session is a new situation, an unknown situation. And if we consider psychoanalysis as a practice of uncertainty (Craparo 2013), even in a skype session, the therapist can also represent that instrument capable of making rapid decisional processes in a probabilistic system with a high level of uncertainty (Galli 2013 ). However, we can not a priori exclude that even a virtual environment can provide the security necessary for the session. But beyond the safe environment of the setting, it is opportune to ask oneself if also in the cyberspace one can generate that “field of forces” capable of initiating an implicit relational weaving; and in such a context, where the couch has been put into latency, the legitimate question on how we can understand what a psychoanalysis is, is amplified even more, in this regard, we think therefore that especially in these new scenarios that are coming to create, more and more, plays a role of primary importance, the in-depth analysis of the therapist, which remains the only means that allows the analyst to internalize the setting “so that the latter always remains present, even if you do not can apply; it will work as a reference in relation to which the analyst will analyze what he does “(Green 2016). But if the analyst’s internal setting, could be that element that even in the absence of a classic setting, would allow the same, in certain situations the development of a session, we will also go to meet and perhaps to distort what is defined ” silent setting “(Bleger 1967) or the invariant elements of the setting, such as the payment, the room, the timetable, the programming of the holidays, these parts have the function of depositing the psychotic anxieties of the identity and the unexposed parts of the Self at change, this silent part of the setting contains and repeats the initial symbiotic reality (Etchegoyen 1990). But obviously, if on the one hand we must distance ourselves from all those orthodoxies that are by nature suspicious of any deviation, we must also be able to accept the limits. It would then be advisable not to talk about online psychoanalysis, but as already described above, of psychoanalytic therapeutic intervention. And one could say that even the skype session puts us in front of a crossroads, the same crossroads that Freud had illustrated through the arts, painting and sculpture. That is, the way of laying and the way of rising, painting adds and enriches, while sculpture takes away and does emerge, the former lends itself to defining psychotherapeutic work, the latter describes psychoanalytic work (L. Aiello et al., 2016). Following this metaphor, the skype session could be understood as painting that can add some new color tones to a situation made difficult by a geographical distance or a decency in the hospital as previously mentioned. After seeing how an online session could change even those elements of the setting that until now had remained unchanged, another unknown remains the absence of the body in the setting, but psychoanalysis in the history of thought has always been a question mark (Mangini 2015) , and should not be understood simply as closeness to bodies, but also as a symbolic dimension; we therefore consider it appropriate to underline that psychoanalysis, besides being the realm of the word, continues to be a therapy of the word, and sometimes we only have words as the sole resource for arriving at insight; and even in situations where one opts for an online session, one can still exercise the art of being with the mind, in which one can reconcile the need to maintain at the same time, relatively immobile the body and extremely mobile mind; therefore also in anomalous and unorthodox situations, and it is hoped that the analyst, even in a virtual setting, where even more all the limits of the setting and the défaillances emerge (Green 2016), can ethically succeed in passing between himself and the other, to make a “crossing the bridge” (Ferruta 2008), to put the “mind to maggese” (Khan MR 1990), to “listen without memory and desire” (Bion 1962), but that can above all also in such situations, “being able to read, looking through, beyond the rationality, objectivity, that delicate and refined set of presence and absence, that knowing how to reach and accept without wanting to capture, a non-predictive science that does not use a priori categories and protocols, since what we deal with are the differences, the peculiarities of each specific individual “(Romano F 2016, p.138).

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