I didn’t think you were listening. Some Reflections on Online Setting and Patient Proxy in the Remote Clinical Relationship

Angelo Raffaele Pennella, Giuditta Maria Bignami


Background: The limitations imposed by the SARS-CoV-2 pandemic on social relatedness (use of Personal Protective Equipment, interpersonal distancing, suspension of face-to-face activities, etc.) forced psychologists and psychotherapists to suspend face-to-face clinical activity for several months. The use of video calls (e.g., WhatsApp, Skype) and videoconferencing (e.g., Zoom, Meet) was the only way to avoid the interruption of psychotherapy and psychological counselling. However, the shift from offline to online psychotherapeutic settings has raised interesting theoretical and technical questions about how to consider the frame of clinical intervention. This article aims to contribute to the reflection on the characteristics of the online setting (videoconference) and its differences and specificities compared to the traditional setting.

Methods: The article proposes a clinical case treated in an online psychotherapeutic setting. The intervention was carried out in the context of a counseling and psychological support service of an Italian university.

Results: After a brief presentation of the case - a young adult with anxiety symptoms - the article describes a relational episode that occurred during a video-call interview (Skype). On the one hand, the episode highlights the characteristics of the patient and, on the other, how the online setting facilitated the expression of the patient's relational patterns.

Conclusions: The case refers to a young adult who seems to develop interpersonal relationships based on presence/absence. The others (parents, partners) are always described as lacking something and, therefore, in some way, "absent". The patient himself is described as lacking something (e.g. masculinity) and shows himself unable to be fully present in situations. However, the theme of presence/absence also characterizes the online psychotherapeutic setting: presence is disembodied, lacking physicality. On the one hand, the clinical case highlights the need to understand the characteristics of the online setting better, and on the other hand, the importance of always keeping frame and process connected. It is fundamental to remember that what happens in the setting and is always an integral part of the clinical intervention.


Online setting; Psychotherapy; Clinical psychology.

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Aafjes-van Doorn, K., Békés, V., & Prout, T. A. (2020). Grappling with our therapeutic relationship and professional self-doubt during COVID-19: Will we use video therapy again?. Counselling Psychology Quarterly, 1-12. https://doi.org/10.1080/09515070.2020.1773404

Baer, L., Cukor, P., Jenike, M. A., Leahy, L., O'Laughlen, J., & Coyle, J. T. (1995). Pilot studies of telemedicine for patients with obsessive-compulsive disorder. The American Journal of Psychiatry, 152(9), 1383-1385. https://doi.org/10.1176/ajp.152.9.1383

Backhaus, A., Agha, Z., Maglione, M.L., Repp, A., Ross, B., Zuest, D., Rice-Thorp, N.M, Lohr, J. & Thorp, S.R. (2012). Videoconferencing psychotherapy: A systematic review. Psychological Services, 9(2), 111-131. https://doi.org/10.1037/a0027924

Baron-Cohen, S. (2011). Zero Degrees of Empathy. A New Theory of Human Cruelty and Kindness. Penguin Press.

Bartoszek, A., Walkowiak, D., Bartoszek, A., & Kardas, G. (2020). Mental well-being (depression, loneliness, insomnia, daily life fatigue) during COVID-19 related home-confinement-A study from Poland. International Journal of Environmental Research and Public Health, 17(20), 7417. https://doi.org/10.3390/ijerph17207417

Békés, V., & Aafjes-van Doorn, K. (2020). Psychotherapists' attitudes toward online therapy during the COVID-19 pandemic. Journal of Psychotherapy Integration, 30(2), 238-247. https://doi.org/10.1037/int0000214

Békés, V., Aafjes-van Doorn, K., Luo, X., Prout, T. A., & Hoffman, L. (2021). Psychotherapists’ Challenges With Online Therapy During COVID-19: Concerns About Connectedness Predict Therapists’ Negative View of Online Therapy and Its Perceived Efficacy Over Time. Frontiers in psychology, 12, 705699. https://doi.org/10.3389/fpsyg.2021.705699.

Berryhill, M.B., Halli-Tierney, A., Culmer, N., Williams, N., Betancourt, A., King, M., & Ruggles, H. (2019). Videoconferencing psychological therapy and anxiety: a systematic review. Family Practice, 36, 53-63.


Boldrini, T., Schiano Lomoriello, A., Del Corno, F., Lingiardi, V., & Salcuni, S. (2020). Psychotherapy during COVID-19: How the clinical practice of Italian psychotherapists changed during the pandemic. Frontiers in Psychology, 11, 2716. https://doi.org/10.3389/fpsyg.2020.591170

Bolko, M., & Merini A. (1989). Il setting. In F. Del Corno & M. Lang (Ed.), Psicologia clinica. Trattamenti in setting individuale. Psicoterapie, trattamenti somatici (pp. 1-19). Franco Angeli.

Bollas, C. (1987). The Shadow of the Object. Columbia University Press.

Cantone, D., Guerriera, C., Architravo, M., Alfano, Y.M., Cioffi, V., Moretto, E., Mosca, L.L., Longobardi, T., Muzii, B., Maldonato, N.M., & Sperandeo, R. (2021). A sample of Italian psychotherapists express their perception and opinions of online psychotherapy during the covid-19 pandemic. Rivista di Psichiatria, 56(4):198-204. http://dx.doi.org/10.1708/3654.36347

Cao, W., Fang, Z., Hou, G., Han, M., Xu, X., Dong, J., & Zheng, J. (2020). The psychological impact of the COVID-19 epidemic on college students in China. Psychiatry research, 287, 112934. https://doi.org/10.1016/j.psychres.2020.112934

Carli, R., & Paniccia, R. M. (2003). Analisi della domanda: Teoria e tecnica dell'intervento in psicologia clinica. Bologna: Il Mulino.

Carlino, R. (2011). Distance psychoanalysis: The theory and practice of using communication technology in the clinic. Karnac.

Christakis, N.A. (2020). Apollo's arrow: The profound and enduring impact of coronavirus on the way we live. Little, Brown Spark.

Di Giuseppe, M., Zilcha-Mano, S., Prout, T.A., Perry, J.C., Orrù, G., & Conversano, C. (2020). Psychological impact of coronavirus disease 2019 among Italians during the first week of lockdown. Frontiers in Psychiatry, 11, 1022. https://doi.org/10.3389/fpsyt.2020.576597

Drum, K.B., & Littleton, H.L. (2014). Therapeutic boundaries in telepsychology: Unique issues and best practice recommendations. Professional psychology, research and practice, 45(5), 309–315. https://doi.org/10.1037/a0036127

Fasano, A.I., & Mandolillo, P. (2020). Dal divano di Freud al monitor del pc: Metapsicologia della terapia online. FrancoAngeli.

Fishkin, R.E. & Fishkin, L. (2011). The electronic couch: some observations about Skype treatment. In S. Akhtar Lanham (Ed.), The Electrified Mind: Development, Psychopathology, and Treatment in the Era of Cell Phones and the Internt (pp. 99-111). Jason Aronson.

Fishkin, R., Fishkin, L., Leli, U., Katz, B., & Snyder, E. (2011). Psychodynamic treatment, training, and supervision using internet-based technologies. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 39(1), 155-168. https://doi.org/10.1521/jaap.2011.39.1.155

Galimberti U. (1999). Enciclopedia di Psicologia. Garzanti.

Grover, S., Sahoo, S., Mehra, A., Avasthi, A., Tripathi, A., Subramanyan, A., Pattojoshi, A. Prasad Rao, G., Saha, G., Mishra, K.K., Chakraborty, K., Rao, N.P., Vaishnav, M., Prakash Singh, O., Dalai, P.K., Chadda, R.K., Gupta, R., Gautam, S., Sarkar, S., Rao T.S.S., Kumar, V., & Janardran Reddy, Y.C. (2020). Psychological impact of COVID-19 lockdown: An online survey from India. Indian Journal of Psychiatry, 62(4), 354-362.


Langs, R. (1998). Ground Rules in Psychotherapy and Counselling. Karnac Books.

Leffert, M. (2003). Analysis and psychotherapy by telephone: Twenty years of clinical experience. Journal of the American Psychoanalytic Association, 51(1), 101-130. https://doi.org/10.1177/00030651030510011301

Lingiardi V. & De Bei F. (2008). L’uso del lettino nella psicoanalisi contemporanea: revisione della letteratura e una ricerca empirica. Psicoterapia e Scienze Umane, XLII (3), 319-356.

Luchetti, M., Lee, J.H., Aschwanden, D., Sesker, A., Strickhouser, J.E., Terracciano, A., & Sutin, A.R. (2020). The Trajectory of Loneliness in Response to COVID-19. American Psychologist, 75(7), 897-908. http://dx.doi.org/10.1037/amp0000690

Maclaren, K. (2008). Embodied perceptions of others as a condition of selfhood? Journal of Consciousness Studies, 15(8), 63-93.

Markowitz, J. C., Milrod, B., Heckman, T. G., Bergman, M., Amsalem, D., Zalman, H., ... & Neria, Y. (2021). Psychotherapy at a distance. American Journal of Psychiatry, 178(3), 240-246. https://doi.org/10.1176/appi.ajp.2020.20050557

McBeath, A. G., Du Plock, S., & Bager‐Charleson, S. (2020). The challenges and experiences of psychotherapists working remotely during the coronavirus pandemic. Counselling and Psychotherapy Research, 20(3), 394-405. https://doi.org/10.1002/capr.12326

Mermelstein, H. T., & Holland, J. C. (1991). Psychotherapy by telephone: A therapeutic tool for cancer patients. Psychosomatics, 32(4), 407-412. https://doi.org/10.1016/S0033-3182(91)72042-2

Migone, P. (2003). La psicoterapia con Internet. Psicoterapia e scienze umane. XXXVII, 4: 57-73.

Migone, P. (2013). Psychoanalysis on the Internet: A discussion of its theoretical implications for both online and offline therapeutic technique. Psychoanalytic Psychology, 30(2), 281–299. https://doi.org/10.1037/a0031507

Mirkin, M. (2011). Telephone analysis: Compromised treatment or an interesting opportunity?. The Psychoanalytic Quarterly, 80(3), 643-670. https://doi.org/10.1002/j.2167-4086.2011.tb00100.x

Mitchell, J. E., Crosby, R. D., Wonderlich, S. A., Crow, S., Lancaster, K., Simonich, H., Swan-Kremeir, L., Lysne, C. & Myers, T. C. (2008). A randomized trial comparing the efficacy of cognitive-behavioral therapy for bulimia nervosa delivered via telemedicine versus face-to-face. Behaviour research and therapy, 46(5), 581-592. https://doi.org/10.1016/j.brat.2008.02.004

Nelson, E. L., & Bui, T. (2010). Rural telepsychology services for children and adolescents. Journal of Clinical Psychology, 66(5), 490-501. https://doi.org/10.1002/jclp.20682

Nelson, E. L., Bui, T. N., & Velasquez, S. E. (2011). Telepsychology: Research and practise overview. Child and Adolescent Psychiatric Clinics, 20(1), 67-79. https://doi.org/10.1016/j.chc.2010.08.005

Palma, B. (2020). Space, boundaries, and presence: Considerations for individual and group therapy using videoconferencing in the time of COVID-19. Psychotherapy Bulletin, 55(2), 18-22.

Pennella A.R. (2013a). Il luogo delle storie e dintorni. Il setting in psicoterapia psicoanalitica. FrancoAngeli.

Pennella A.R. (2013b). Il setting. In M. Grasso, B. Cordella, A.R. Pennella (Eds.), Metodologia dell'intervento in psicologia clinica (pp. 49-100). Carocci.

Pennella A.R., & Spaccarotella M. (2020). Relazioni cliniche a distanza e doppio setting. Una ricerca pilota e alcune riflessioni sul setting online. Psichiatria e Psicoterapia, 39(3), 200-218.

Poletti, B., Tagini, S., Brugnera, A., Parolin, L., Pievani, L., Ferrucci, R., Compare, A., & Silani, V. (2020). Telepsychotherapy: a leaflet for psychotherapists in the age of COVID-19. A review of the evidence. Counselling Psychology Quarterly, 1-16. https://doi.org/10.1080/09515070.2020.1769557

Reed, G. M., McLaughlin, C. J., & Milholland, K. (2000). Ten interdisciplinary principles for professional practice in telehealth: Implications for psychology. Professional Psychology: Research and Practice, 31(2), 170-178. https://doi.org/10.1037/0735-7028.31.2.170

Richards, A. K. (2001). Talking cure in the 21st century: Telephone psychoanalysis. Psychoanalytic Psychology, 18(2), 388–391. https://doi.org/10.1037/0736-9735.18.2.388

Rochlen, A. B., Zack, J. S., & Speyer, C. (2004). Online therapy: Review of relevant definitions, debates, and current empirical support. Journal of Clinical Psychology, 60(3), 269-283. https://doi.org/10.1002/jclp.10263

Rossi, A., Panzeri, A., Pietrabissa, G., Manzoni, G. M., Castelnuovo, G., & Mannarini, S. (2020). The anxiety-buffer hypothesis in the time of COVID-19: when self-esteem protects from the impact of loneliness and fear on anxiety and depression. Frontiers in Psychology, 11, 2177.https://doi.org/10.3389/fpsyg.2020.02177

Ruskin, P. E., Silver-Aylaian, M., Kling, M. A., Reed, S. A., Bradham, D. D., Hebel, J. R., Barrett, D., Knowles III, F., & Hauser, P. (2004). Treatment outcomes in depression: comparison of remote treatment through telepsychiatry to in-person treatment. American Journal of Psychiatry, 161(8), 1471-1476. https://doi.org/10.1176/appi.ajp.161.8.1471

Russell, G.I. (2015). Screen Relations. The Limits of Computer-Mediated Psychoanalysis and Psychotherapy. Routledge.

Saltzman, L. Y., Hansel, T. C., & Bordnick, P. S. (2020). Loneliness, isolation, and social support factors in post-COVID-19 mental health. Psychological Trauma: Theory, Research, Practice, and Policy, 12(S1), S55-S57. https://doi.org/10.1037/tra0000703

Santhiveeran, J., & Grant, B. (2006). Use of communication tools and fee-setting in e-therapy: a web site survey. Social work in mental health, 4(2), 31-45. https://doi.org/10.1300/J200v04n02_03

Saporta, J. (2008). Digitalizing psychoanalysis and psychotherapy. American Psychoanalyst, 42(2), 1-9.

Stanghellini, G. (2020). Selfie. Sentirsi nello sguardo dell’altro, Feltrinelli.

Saul, L.J. (1951). A note on the telephone as a technical aid. The Psychoanalytic Quarterly, 20(2), 287-290. https://doi.org/10.1080/21674086.1951.11925845

Scharff, J.S. (2012). Clinical issues in analyses over the telephone and the Internet. The International Journal of Psychoanalysis, 93(1), 81-95. https://doi.org/10.1111/j.1745-8315.2011.00548.x

Scharff, J.S. (2013). Technology-assisted psychoanalysis. Journal of the American Psychoanalytic Association, 61(3), 491-510. https://doi.org/10.1177/0003065113485423

Semi, A.A. (1985). Tecnica del colloquio. Raffaello Cortina.

Serafini, G., Parmigiani, B., Amerio, A., Aguglia, A., Sher, L., & Amore, M. (2020). The psychological impact of COVID-19 on the mental health in the general population. QJM: An International Journal of Medicine, 113(8), 531-537. https://doi.org/10.1093/qjmed/hcaa201

Vallario, L. (2020). Il trasferimento delle terapie dall'offline all'online: una questione di setting e relazione. Journal of Psychosocial Systems, 4(1), 6-19. https://doi.org/10.23823/jps.v4i1.65

Whittaker, S. (2003). Theories and methods in mediated communication. In A.C. Graesser, M.A. Gernsbacher, & S.R. Goldman (Eds.), Handbook of discourse processes (pp. 243-286). Lawrence Erlbaum Associates Publishers.

Winnicott, D.W. (1975). Gli aspetti metapsicologici e clinici della regressione nell’ambito della situazione analitica. In D.W., Winnicott (Ed.), Dalla pediatria alla psicoanalisi. (pp. 332-350, C. Ranchetti, Trad.). Martinelli (originally published 1954).

Zarem, S. (2001). Choosing the telephone: A clinical exploration of potential advantage. Issues in Psychoanalytic Psychology, 23(1-2), 49-57.

DOI: https://doi.org/10.13129/2282-1619/mjcp-3155


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