I have never worked with a patient for whom English was not their first language. However, I have a British patient, and we often find that words have different meanings in American English and British English. He also sometimes insists that cultural differences explain his behavior. For example, each time I brought up his excessive drinking in the past, he explained it as an accepted part of his culture and not his individual problem.

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Recently, I was contacted by a Greek woman responding to one of my blogs in Psychology Today. She wanted to begin psychotherapy from Athens using Skype. I have always believed that telephone sessions were less useful than in-person therapy, but since the pandemic began, I have rethought some of my assumptions. I am working with all my patients by phone, and I think it is going extremely well. But I have worked with them for a long time; I know what their silences and nuances of voice mean. Starting with a new patient half-way across the world seemed daunting. In addition, she wanted to have face-to-face sessions rather than phone sessions. I thought that might be difficult for me; I was used to talking on the phone. I thought I might feel more pressured to talk during pauses and be more conversational than in a session in my office. I was not sure it would work, but we both agreed to try it and see how it felt.

Sophia is a psychologically sophisticated woman with a great deal of prior therapy experience. She is fluent in English but often strains to choose the “correct” phrase. She does not want anything to be “lost in translation,” so we often spend time trying to find the exact phrase that captures her meaning. I have not felt this was simply a language issue. Rather, I have felt it was a process through which she gains clarity about what she is feeling. When she describes her feeling and then tries out a few phrases and I suggest one or two more, the back and forth usually ends with a phrase that captures her feeling exactly, and she experiences psychic satisfaction from that.

This week we were discussing the influence Skype has on her treatment. She is disturbed by not seeing me in person and often mentions how much she would like to be in my office in person, even once. She also brought up the issue of how much meaning might be lost because she is not speaking in her “mother tongue.” But she pondered that and said that, on the other hand, she realized she was confiding things in me that she had never discussed in her earlier treatments. She said that she did not feel concerned about my judgement of her the way she had been with her Greek therapists.

I have only had six or seven sessions with Sophia, and she has not mentioned her mother’s being critical of her. She has, on the other hand, talked about feeling that her mother did not protect her from a long-term abusive relationship in her teens. Nonetheless, I suspected that her concern about her prior therapists’ judgement of her was related to her mother transference.

“So maybe not speaking in your ‘mother-tongue’ frees you from worrying about your mother’s judgement,” I offered.

“Yes,” she laughed. “And none of my other therapists ever asked me what I was feeling. You ask me what I’m feeling throughout the session. They just made interpretations about what I said. I do not use words that express feelings in my ‘mother-tongue.’ That’s why I so often must stop and think about the right word or phrase in English. I don’t even know it in Greek!”

From the beginning, working with Sophia meant I would have to engage with her in a variety of ways that were alien to me. I had to accept unusual parameters for the treatment to work. I usually tell patients my fee, but I did not know what the fee structure was like in Greece. Sophia told me the fee that psychoanalysts with my credentials and experience charge in Greece, and I accepted that. Also, I did not know how to use Skype. I had to practice it before I spoke to her so that I would know which icon to click on when she called. But, nevertheless, I was fumbling around during our first session, and that shortened the session time. And then we had to figure out how she would pay me. She suggested a wire transfer, but I knew my bank charges for receiving transfers. I also knew that there would be a problem with exchange rates. We had to work together to iron out all of the wrinkles. She paid me an incorrect amount the first time she paid me, because the exchange rate changed and she didn’t know what my bank was going to charge for the transfer. That required emails back and forth—something I am usually loath to do. I had to accept that if this treatment was going to work, we had to have a working relationship outside of the treatment. In many ways, this treatment was not going to be in my own “mother tongue.”

Working with Sophia has been very gratifying because I am questioning some of my basic assumptions about treatment. First, in this case, teletherapy is working as well as in-person treatment, because we are exploring Sophia’s feelings about it, and that is opening issues about trust and attachment that might have taken much longer to get to in an office-treatment setting. Second, working on Skype has not, as I had earlier assumed, made developing a working alliance more difficult. To the contrary, seeing her face has helped me tune in to what she is feeling. Finally, I think we have developed a strong connection (pun intended) through Skype and are able to work with transference, resistance, and dream interpretation.

Although I do not think teletherapy is ideal for every new patient, working with Sophia has challenged my general views. She has been in psychoanalytic therapy before and seems comfortable with brief silences. Sofia has a strong observing ego and can associate during the pauses and then discuss her associations. In sum, I feel less rigid about the parameters of good treatment and have expanded my horizons. In the future, even when the pandemic is over, I will be more open to considering teletherapy with new patients.

File under: Musings and Reflections, Online Therapy