“Sorry, you cut out for a minute…” Why cues matter for communication and the implications for remote therapy

Post by Dr Chloe Campbell, Deputy Director of the UCL Psychoanalysis Unit

Reading time: ~ 6 mins

The remote therapy experiment brought about by the pandemic has had a silver lining, as therapy has become more accessible to many people. Keeping some form of online therapy is desirable for this reason, but it does raise new challenges for communication. Chloe Campbell reflects on how a psychological understanding of trust can help us understand online communication better.

Psychological therapy is not new or special: that is why it works. Humans beings have – for as long as we have had language – sought out other people’s minds, thoughts and perspectives in order to regulate their own state of mind.

Infants do it all the time and perhaps most obviously – a baby or young child is not only dependent on their caregivers for physical survival, but also to restore their sense of comfort, safety or to help them make sense of the world together.

This joining of minds, known as ‘joint intentionality’, is crucial to human development. Recent evolutionary thinking has suggested it underpins the sophisticated social cognitive skills that make the human species unique. It enables teaching and learning, sophisticated planning and collaboration – in essence it makes social cohesion and the development of culture possible. 

To be able to do all these complicated and demanding social cognitions, we need to be able to think about the mental states of other people and ourselves, an ability known as ‘mentalizing’. But mentalizing requires imagination – we cannot know for certain what is going on in other peoples’ minds, and even thinking about our own mental states is a highly abstract undertaking.

The human imagination allows us to do extraordinary things – from being able to think sensitively about someone else’s pain or distress, to being able to write and read great literature, to being able to make the abstract leaps in ideas that lead to ground-breaking scientific breakthroughs.

We all need to access to other people’s thoughts to help us manage our own – to moor our imaginations to something more  helpful for us, or indeed with reality

The flipside of our marvellous imaginative capacities is that sometimes our ability to think in such ways can, when unregulated, lead to intense psychological distress. Many forms of anxiety and depression can be understood as being, in some way, the product of our minds working away at great abstract capacity but with insufficient alignment with our social reality. 

This is where other people’s minds come in. We all need, at times, to access to other people’s thoughts to help us manage our own – to moor our imaginations to something more in line with what is helpful for us, or indeed with reality.

This is the power of joint intentionality and cooperative thinking. But a further complication in all this arises from another downside of human social complexity: not all humans can be trusted and opening up to the wrong person could leave you vulnerable.

As a result of this, we have also evolved the capacity to be highly sensitive to cues from other people that might suggest whether or not they (a) have something useful to say and (b) have our best interests at heart.

And it is here that the communication that is relevant to effective psychotherapy comes in. The kinds of cues that we are sensitive to are often highly interpersonal.

If we feel the other person is truly interested and capable of recognising us – even those parts of us that are hidden, perhaps even partly to ourselves – then that is a powerful cue that the other person is sufficiently invested in us for us to be able to think with them, to learn from them, and to use their mind to regulate our own.

Once we have had some practise accepting this in the therapeutic relationship, we can go on to build on what we have learnt in our daily lives. With a bit of luck, a virtuous circle might be activated – and treatment has become “effective”.

Of course, if the outside world does not support these developments, then it is much harder, and in some circumstances perhaps impossible, for the virtuous cycle to really keep rolling. After all, if we live in a hostile environment, where other people’s minds aren’t capable of investing benignly in each other’s, it would be a mistake to adopt such cooperative openness to others’ mental states.

So, where does this leave us with remote therapy?

The task of the remote practitioner is the same. Their work depends on their capacity to evoke in the client the same sense they have been recognised, that the practitioner is interested and invested in the client’s mental state, and is able to tolerate and accommodate the complexities this might involve.

Remote therapy can create particular challenges for this – but also perhaps offer some advantages.

Returning to an evolutionary perspective, the initial challenge arises from the fact that we adapted the capacity to read these signals in small, face-to-face social groups.

Working remotely creates challenges but more than ever it should focus us on the value of thinking together and communicating thoughtfully.

The role of signals such as eye contact, responding to body language and contingent responsiveness – the back and forth quality of shared conversation – are liable to be distorted in online communication. The person you are talking to may cut out for a minute and the conversational flow may be disrupted by time-lags and audio difficulties.

However, some individuals, including those who may feel others are not benign or well-intentioned towards them, may find another person’s attention overwhelming. For them, the buffer of online remoteness may provide some space to assess cues at a safe distance. The remote practitioner needs perhaps to work that bit harder to think about the cues, and to show that they have understood.

An example of this is the formulation, common at the beginning of therapy. We argue that the reason a skilfully done formulation is so important is that it is a thoughtful and explicit demonstration of the therapist’s interest in the client’s state.

In remote therapy, formulation is perhaps even more important given that other cues may be harder to convey remotely.

The need to work remotely creates challenges but perhaps more than ever it should focus us on the value of thinking together, of communicating thoughtfully and attempting to recognise and acknowledge mental states in all their complexity. And of course this includes the practitioners who themselves need to be appreciated and recognised for their efforts to connect with their clients, under conditions of such uncertainty.