Introduction

The main purpose of this paper is not to describe in detail the individual psychotherapy applied in the case of Jason (almost 17 years of age), but rather to demonstrate how the use of an Internet voicemail was useful. It enabled Jason and myself quickly to come to terms with and overcome what was a very delicate phase. 

Jason’s parents separated when he was five years old. Since then, he lived mainly with his mother, in a small rural village, and had also regular conflict-free contact with his father. He has one sister, Joanna, one year younger, and he gets on well with her.

Since he was 15, Jason had been coming for consultation off and on, in connection with his poor results at school and his abundant use of the Internet. This was nothing more than some friendly support therapy, along with a few father-child and mother-child interviews. I had not seen him for months when his father phoned me : « The Internet is not the problem any more…something is very wrong with Jason » The youngster was sullen, withdrawn and increasingly irritable. We therefore resumed the therapy. We still had a good relationship, but it was a conventional and evasive one, focusing on fairly general subjects (school, young people, the Internet, etc.)      

The critical sessions of psychotherapy

  Overwhelmed by fear of death 

Ten days later, his father called me on the phone, very worried because Jason was getting worse. He had an overwhelming fear of death that made his life a misery. I gave Jason a quick appointment and he confirmed me his almost panic fear : it was so bad that he couldn’t keep up with his schoolwork and  he often felt his pulse to check that he was still alive. He first claimed that he couldn’t connect this recurrence to any specific experience or to any new questions he had recently come up with about life. I replied that one possibility was guilt and self-aggression: « It’s as if part of yourself is attacking you and trying to kill you (...) Could it be that you’re blaming yourself for something, that you feel guilty about something serious that you daren’t admit? Or something you can’t remember right away? » Off the top of his head, nothing came to mind. Then, as the session was over, I asked him to seek what he could find for next time. 

Because he lived over a hundred kilometers away, it was urgent and  we are both interested in the Internet, I suggested we do the next session five days later over the voicemail Messenger, using a webcam and a microphone. He gladly agreed to the idea, as did his father when I informed him.

 The first webcam session

Five days later, using MSN, Jason told me right away that his anxiety had not abated and that he wasn’t working at all at school. I listened as he described his concerns in some detail, then I reiterated the idea that perhaps he was blaming h and punishing himself for something. I discerned right away that he became very uncomfortable, sad and ashamed[1]. He confessed he had something really worrying to tell me, but that he would never dare say what, as he was really too ashamed. I took this seriously and gave him some general encouragement (« Try, Jason. It’s important for you to express yourself ») Then, as he remained inhibited, I suggested, half joking, a few specific ideas which I had the intuition they were probably not pertinent to him: « What! Are you telling me that you have really sadistic, scary, horrible fantasies when you are jerking off? Or do you sometimes drink your piss? » That made him laugh (well, a little), and he answered: « If it was only that! » He kept saying that he felt too ashamed…so, he was willing to write it to me, but not to say it out loud and especially not when he could see me when he told it[2] .

 I agreed to turn off the video function ; Jason could still hear me, but he just  wrote to me. I went on talking to him, except at the beginning when, to encourage him, I wrote a few ideas that revolve around two fundamental human transgressions: « What do you have so serious, so unthinkable to tell me? Have you killed somebody? Have you sex with your mother? » J: « It’s almost that. » Dr H: « Come on, Jason, explain ! » Then, spurred on  by my specific encouragement, he wrote in brief sentences that for seven years he had had incestuous relations with his sister Joanna ; he eventually admitted that it was somewhere between the age of 7 and 14.

 He felt utterly ashamed, and convinced that he was solely to blame for it, because he was one year older However, they both took the initiative. There was no constraint. Sometimes he wanted to, and sometimes it was her. It was he who decided to stop when he was about 14: « because it was going too far » (incipient penetrations and ejaculations): « Three drops, no more », he added, quite ingenuous…nevertheless, except towards the end, to use his words, it remained « basic » ( i.e. no penetration of any kind ). These intimate encounters took place while they were alone at  house, and they always kept it a secret. 

As he was explaining how  the sex-activities gradually had developed, I mentioned that, in my opinion, their deep nature had evolved : from being initially banal sexual games, they  had become real, structural incest [3] : for a very long time they had been like partners, each other’s only company, and, as Jason admitted, there was a lot of affective complicity between him and his sister : « We got on very well. It was almost love »

 His recent fear of death had started a few days after he found out that his sister had consulted herself a psychotherapist. J: « That destroyed her too, and I was to blame for everything »; nevertheless, he added: « But she says that it’s not because of that. We talked a little about it, and she claimed that it hadn’t affected her ... that she remembers it like a nice dream ».

Of course, this description didn’t come out all in one go. Once Jason started writing, short phrases came up in quick succession : some of them came spontaneously out, like a confession that has to be vomited out once it has started, while other phrases prompted me to ask questions about specific details. A few times I got the impression that he was playing down some of the more embarrassing aspects (the fact that it had gone on for a long time, the onset of puberty, etc.) 

Eventually I considered that Jason had just about said everything he had to say for this first written session, so I asked him to switch the  video function back on. He didn’t object, so I could see live what happens after someone confesses to serious wrongdoing. Initially all I could see on the screen was part of Jason’s forehead, turned the other way and almost lying on the desk. However, little by little, sometimes spontaneously and sometimes at my prompting, he lifted his head and moved his face back into the field of vision, and I was delighted to see that he stared at the camera two or three times. In other words, he had the courage to look me in the eye. 

The last part of the session. 

◊ - First of all, we engaged in a little ritual. I asked him to repeat the following sentence after me, bit by bit, three times and aloud: « Dr Hayez/with my sister/I engaged in/heavy/sexual activity/for several years. » Although he was initially somewhat taken aback and embarrassed, Jason quickly went along with this ritual[4] and  just after I once again had eye contact with him.

 By acting in this way, I could be accused of being a control freak and quite naive ( with an approach redolent of the Coué method ) However, I have no regrets : I didn't make him  reveal something hidden, but I simply collated snippets of his own language and made the text into a unified whole.  Nevertheless, the text is not trivial : it strikes at the heart of the confession he was brave enough to make ;in addition, I get the impression that this helped us save time and more : at this point he understood  that I still kept respect for him, while having heard the full extent of his « crime ». 

◊ - We then evoked the meaning of what they had done -incest or simply sexual game- and the responsibilities involved. Among other shared ideas and questions, I suggested he should get the book I had written about child sexuality[5], read my opinion about sibling sexual activities i and then discuss it with me.

Finally, we talked about the gravity of their actions and his current self-esteem.I didn’t want to reassure him too quickly, but rather to listen first his own assessment, which turned out catastrophic : he felt like a kind of monster. Only after listening to him, I suggested how I differed from his opinion: Therefor, I reminded him about an episode in the Gospel of John[6]  where Jesus talks about an adulterous woman: « Let him among you who is without sin, first cast a stone at her [ to stone her ] … [they] went out one by one, beginning at the eldest, even unto the last » . He then asked me if it was just in the context of my work that I made him this comment and if I still had some esteem for him. We talked about this a little. I told him that I basically continued to have esteem for him in my position as a human being, a representative of the community in whom he had confided, without approving the incest that had taken place

Before signing off, we made an appointment for six days later, either by webcam or live, whichever he preferred.

The heart of the crisis

 In the two days that followed, I thought of Jason quite often and on Sunday evening, I sent him this e-mail:

Dear Jason,

I was very touched by the courage and confidence you showed. Here are some of my reactions:

- If things happened as you have explained, you are wrong to assume all responsibility. Both about the same age, it’s 50-50[7].

- Now that you have embarked on something, you have to go all the way. You have  told me much of the facts, but  it remains perhaps the most difficult bit,  things that make you even more ashamed ( for example, I am somewhat puzzled by the episode of your three drops of sperm ... Were you both in early puberty in the later years? Could she have got pregnant if you hadn’t stopped? Etc.)

- Try to talk with Joanna and look her in the eye ... She pretends  she has come to terms with it. Is it likely? More for her than for you? Try to ask forgiveness of each other for a serious mistake from which you have to move on ... Tell your sister that I would be glad to meet her some time with you ... You can find some pretext to come over to my place for your parents, to safeguard your intimacy !

- Aside from your guilt, are you also afraid that your sister might let the cat out of the bag at his psychotherapist’s? If so, ask her, but of course you can’t demand anything from her. 

- Lastly, is all this episode of yours over for good? Is your sister still an object of your sexual fantasies?

As you see, we still have our work cut out for next session. Webcam or live ?

 

 On Monday evening, Jason called me on his mobile. He said he was in a kind of quandary; he was relieved, but he also felt worse. He mentioned my e-mail, in which he wanted to discuss some points. And he asked me if he could talk to me sooner, but « like the last time, because I couldn’t look you in the face » I agreed and gave him an appointment by webcam for the same evening three hours later.

Following webcam session 

 Monday 8.30 p.m.: Jason kept the video and the audio channels on, but he hardly spoke or looked at me. He expressed himself in writing, sometimes spontaneously and sometimes in reply to my questions. I expressed myself orally. 

◊ - He was sleeping very badly (he fell asleep at about 2 o’clock in the morning), and was still very anxious. He asked me to give him medicine to help him, and we put together a treatment based on benzodiazepines, provisionally and subject to further adjustments and prescriptions. 

◊ - He told me more about his current feelings and  ideas , partly in reaction to the hypotheses I put forward in my e-mail : He still got on well with his sister, but at this point they tended more to « tease » each other ( perhaps to keep their distance ? ), and she no longer aroused sexual thoughts in him.

◊ - Not only was he ashamed, but he was afraid, fearing that his sister would reveal the incest to her therapist who would then tell her mother (she was a friend of the mother !!) This could mean for him a « terrible tongue-lashing » because he was the elder brother.

Of course, I promised to discuss this with him again. At that point, however, I put forward my new conviction : The responsibility is fully shared between him, his sister and their parents  ( lack of vigilance on the part of the parents ), He once again stressed that it was he who wanted to stop when he was 14 years old because: « I felt I had been an idiot for long enough » 

◊ - Finally, I asked him to tell me  some concrete details of the incest[8]. He claimed that he couldn’t remember right away, and immediately added: « Oh yeah, it’s coming back » 

I asked him to describe what happened the first time. Initially he could just remember one detail: they were in pyjamas in his bedroom and they were giving each other a back massage. I also asked him what they were saying, how each of them referred to the other’s sexual organs and the things they did together, but he told me that all this happened in complete . He added once again that it was « basic[9] : We looked at each other ... I touched her ... I didn’t masturbate at the time » I asked him how he started masturbating. He discovered how to practice himself when he was about 11 years old. I told him that that was the way things happened for many boys and for me too: initially you have no idea, and then all of a sudden, it’s as if a little lightbulb appears from nowhere. I felt it was important to make him understand that I was also sexual. When I insisted a little (« So you said to her, show me your ...? »), he answered that he was hurt by the words « show me », because that made it look as if he was giving orders.

It was soon time to sign off. I told him that we still had work to do and he replied  he didn’t have the courage to tell me face to face, but he would no doubt send an e-mail to explain. We made an appointment to have a webcam session the following Wednesday at 7 p.m.  

Father making a phone call

 On Tuesday evening, Jason’s father left a message on my answering machine: « My wife and I are worried. He says he has a big problem that he talks to you about, that he won’t discuss at home and he assures us he will be better after the Easter holidays. He’s not sleeping ; last night he went to sleep with his mother, and held her hand until four o’clock in the morning. He also told her that it would be better if he didn’t exist and it would be best for him to die ».

 I phoned his father on Wednesday in the morning. I listened as he explained  once again how worried they were. After, I replied that the situation was similar to the example that I would give him, but that of course did not concern Jason: « An 11-year-old boy pushes his enemy down the stairs, who is then confined to a wheelchair. The boy doesn’t get caught and doesn’t own up. How will he feel when he will be 17 years old? »[10] .

Based on this hypothetical situation, I discussed ideas with his father connected with tolerance and support. I admitted too that it would be better for Jason to find a way to talk about it to him and/or to his mother, but that it was important not to pressure him. Finally, I mentioned that it would be good to say to his son at some opportune moment: « Children sometimes do things that are really wrong, but real parents can listen and forgive ».

Jason misses his appointment

 On Wednesday evening, Jason missed his appointment and didn’t reply to an e-mail in which I asked him for news. I thought: Maybe I got carried away with my desire to save him with a quick fix, and maybe I asked him too many distressing questions. Of course, he would have to face it sooner or later, but had I perhaps harassed him without meaning to?

 I hesitated to send him another e-mail to share these thoughts and to remind him that he could talk at his own pace. I finally concluded that having missed his appointment, was quite good for Jason ... and for me too. He could see that he was still free and that he was not under my control as his therapist. As for me, it helped me cool off in my zeal to save him. Lastly, it once again gave him - and not me! - the initiative to decide (freely) if he wanted to encounter me[11]. I decided to wait until Friday, when we would have the next session. Confirmed and adde

 Emerging from the crisis 

On Friday afternoon, his mother phoned me to ask if Jason had an appointment for that evening. I, and that he could either come to my office or use the webcam.

He appeared on the webcam at the time we had arranged. Unfortunately, the audio system didn’t work, so we had a written chat session, with the video function on. He was concentrating on what he was writing. Now and again, he was peeking right at the camera ( so he could see that he was looking at me straight in the eye ), and a couple of times I encouraged him : « Come on, Jason, look at me ! » ; I still felt that this kind of prompting was good for him : when I suggested him to look at me, it wasn’t to judge him, but to make him appreciate my fellow-feeling for him.

 Here is what we talked about, in no particular chronological order: 

-He once again stressed that he never had physically forced his sister. Of course, convincing me - and perhaps convincing himself ?? - was one of his most important objectives. When either of them didn’t fully want to, whoever did used charm and said « please », and this often got results. I commented that, if the scenario unfolded thus, no, it wasn’t force, but rather a kind of game of seduction that is a feature of any loving relationship. What was abnormal was not the dynamics  of their relationship, but his nature itself, which consisted of much more than simple sexual frolicking.

- He then added that he still gave himself most of the blame, because he was one year older. I replied that, if he had told me everything, I still disagreed:  by giving himself all the blame, he could be showing machismo, as if girls were brainless creatures. This made him smile.

 - After, we focused the discussion on what had triggered their sexual desire  when he was seven years old. In his memory,  it was something he had seen: it then became a picture in his mind that had often come back to him from his very early age. For him, it was the enigma: why did that scene have such a profound effect on him? Why did he think about it so often? 

-And then, without realizing it, he described a beautiful wildly primitive scene: his sister and he had seen horses mating[12]  and wanted to do like them. And this mating scene was branded in his mind in fiery letters, triggering incest the first time and many other times, and remaining in his mind as a painful and lasting enigma.

One of the specific benefits of written chat sessions came out when I saw that he spelt wrong the French word « saillie » (mating); he wrote « sallie » (with undertones of dirtiness: salie=dirty) and then « saïe » (that may suggest the idea of pain: Aïe! = Ouch!) He admitted that he could never correctly spell the word « saillie ». The point is that many young children of his age entertain dirty or sadistic ideas about the sexual act among adults, and he had had unnatural relations with his sister. This Freudian slip was almost too neat to be true! I thought it best simply to show him the correct spelling but to make no other comments (as it would have been rather brutal at that particular juncture)

-I asked him if, at the beginning, he had any intuition that their sex game had something to do with the transmission of life…Did he already know something about parental sexuality and where babies come from?

 He answered: “No”, but they had wanted to imitate that powerful sense of oneness between animals, and it was this imitation that he felt guilty about! In the meantime, I suggested that perhaps he felt so ashamed because he wanted to imitate animals - adult animals - whereas he and his sister were human and, what’s more, children. No comment. 

 -Later during the session, I mentioned again to Jason that I was worried about his sister’s possible psychological health. I repeated  he could talk to her about our sessions and that it might be good for her to come and see me with him and talk about what had happened. He wrote back that he would no doubt do that, but he wasn’t sure if she would agree to come. But he said that she might agree to talk to me over the webcam.

And after                             

The session ended. The Easter holidays were coming up, and I couldn’t meet him for two weeks. I told him that he could email me  if he needed, and made the next appointment for a live session.  The rest of the therapy was peaceful, with no really new highlights. Two final fun details: -Towards the end of the therapy, Jason had regained more positive self-esteem. And he made me this awful request, imbued with a little male rivalry, and typical of a teenage boy who is doing well: "If you had a daughter, would you accept that she go out with a guy like me?" I let you guess how I treated his question !  - Jason kept Chilean degus in his room and was very fond of them. I knew it because, during a webcam session, I heard a noise and asked him about it ; he showed me the cage and the little animals.

I remembered then the importance that a lot of adolescent therapists gave to direct and symbolic payment of the sessions by their young patients. Given that to a modest degree I have become intimately involved in Jason’s life ( I was familiar with his room, etc.) , so, towards the end of the therapy, I asked him, as a kind of payment for our work, to give me one of his  degus, along with a cage and instructions on what to do with it. I thought about finding a place for it in our waiting room Indeed, he was pleased at the idea of this living, real and symbolic representation of a kind of link between him and me… and I and my centre inherited the animal.

Discussion

Incest in siblings

In a significant number of siblings, fraternal relations remain chaste or almost. When this is not the case, there are four categories of sexual practices[13]. Going from more to less frequent:

1.Sexual games, even frank searches for sexual pleasure, mutually agreed, without too significant age difference: for example, common masturbation of young teenagers in front of a porn site. They are most often episodic, without including particular affective component linked to fraternal status. The sibling is simply identified as the closest partner, the “buddy” that one can get to hand (if I dare say) !

2.Real sexual abuse with physical or intellectual violence against the victim. They also do not specifically target the brother or sister but "the closest prey". Like all the other abuses, it is dictated in variable proportions by the search for sexual pleasure and that of power.

A particular problem exists when the age difference is strong (e.g., 17 years-8 years… or 11 years-4 years). The elder he can show himself full of “nice” seduction  and is not always aware that he is abusing, if one does not make him aware of it! However he almost inevitably abuses the candour and the cognitive, emotional and physical weakness of the youngest…. Furthermore, his choice of partner, if repeated, is worrying as regards the mental and sexual health of this elder

3.Even more rarely, there are real incest with mutual consent, most often of medium or long duration, that fall into two sub-groups:

--- Love passions, accompanied by sexual fusion[14] .

----Old lovers with rigid and lazy habits. Here the affective relationship is positive without being passionate. The two children or teenagers involved have learned and got into the habit of making love together like a faithful old couple. They are no longer looking for an exogamic partner.  I place Jason and Joanna in this subgroup ("We got along very well; almost love")

----Even more rare, the combination of a unilateral love passion and a more or less clear violence made to the partner. We can then speak of incest with abuse. 

The impact of the Internet on Jason’s therapy 

1.If there had only been IRL meetings, Jason being paralyzed by his inhibitions, it would have taken months for him to pluck up the courage to reveal the incest. He felt the need to get it off his chest, of course, but he also benefited from this strong feeling of security afforded by Internet chatting. Whether communication be via a webcam or a simple written dialogue,  what is said is  coloured by the following  impressions:  tremendous closeness, warmth and encouragement ( for example, we could see each other close-up attentively listening to each other and our voices resonated ), and, on the other hand,  certainty of total protection from any  direct intrusion by the interlocutor.

Colleagues have told me that in certain circumstances the webcam can be a modern-day confessional. I think the comparison holds. In a confessional, a thick timber frame protects the penitent from the thunderbolts he imagines may be hurled down by the gods.. Moreover, an experienced father confessor is supposed to be empathetic and open ... just like a psychotherapist.

Proceeding from this analogy, I hypothesized that when Jason was looking straight into his webcam, he was looking me in the eye. And so, the moment it happened, his guilt eased and he recovered more self-esteem.  

However, is this improvement as deep and lasting as when occurs IRL  the physical meeting of the therapist and the patient? More or less! The therapist acts as a witness for the community and can therefore represent it and extend forgiveness from the community for the error committed, but such forgiveness can be embraced in all its forcefulness only if it is extended through the intimate contact of two persons who are close. Face to face, each side dares to open up to the other, spiritually and physically, giving him something of himself, risking the unpredictability of the reaction of the other.

Therefore, even for patients who live very far away, it is essential to alternate between webcam and live sessions, even if the alternation 1/1cannot always be perfectly coordinated.

2.Besides, they are also formal advantages when including contemporary technological tools in psychotherapies; 

 -Speed: Combining e-mails and chat sessions (written or audio-visual) with physical sessions provides for tremendous variety in terms of timing, duration and meeting format. It helps the therapist to adapt to the teenager’s schedule and to their very intense, fluctuating and fast-moving world of emotions

-Flexibility in the use of communication channels:  I made use of the different degrees of contact according to the situation, letting myself be guided by Jason’s tolerance

Rather than make the assumption that Jason’s need to hide sometimes from my gaze was a harmful avoidance tactic, we should perhaps bear in mind the ritual adopted in conventional psychoanalysis: the patient cannot see his psychoanalyst, but he can be seen by him. Was this position adopted to help the patient think, without being distracted? Sure, but it is perhaps also done to create the impression (or even the illusion) that he is out of sight and therefore beyond judgment?

Who were my interlocutors & Who did I care for?

1.Jason himself, certainly! He had an initial therapeutic request, that of being freed from his recent anxieties of death.

Suspicious request? I also guessed his almost panic fear that his sister would make revelations and that then the sky would fall on his head (the wrath of Zeus, another great specialist in incest!) Nevertheless his anxieties have subsided over time, although he had become more certain that Joanna would remain silent.

 He was the one who helped stop the incest, but the discomfort did not go away. So, I treated him like a depressed and neurotic patient

2.I imagine his feeling of repairing himself would have been even more complete if he had been able to converse with Joanna in front of me. In addition, I could have better realized her path and perhaps given her encouragement so that she freed herself more with her own therapist.   I made the invitation one or the other time, but he was not able or unwilling to invite his sister and I respected his freedom.

  1. I maintained confidentiality towards the parents: It was my own intuition and also a Jason's request, dictated by anxiety no doubt, but perhaps also by other motivations: claiming his privacy and a right to his secret garden; anger at parents who had failed to watch, etc.

At first, I thought and I communicated to him that he would feel even better if he and his sister could talk to them about their incest. I represented them as the most central elements of this human community whose fundamental law  had been transgressed.

I imagined that, during this solemn meeting, there would be acknowledgment of the fault, then blame, then forgiveness and that this process would constitute a "bonus" in the self-repair of Jason and Joanna. Still in my mind, during an ideal dialogue, the parents should have recognized their prolonged lack of vigilance, which was also blameable and forgivable.

Over time, however, I feel less confident in thinking that the inclusion of the parents could have been so restructuring. What are the arguments rather against?

- Jason and his sister did well on their own to get out alone of the dead end they had gotten themselves into.

- The serious transgression is over; Jason does not endanger anyone by his actions and his plans and his sister gives herself the means to heal.

- Jason admitted his fault before at least one member of the human community, me, and had the opportunity to discuss it in a nuanced manner.

- To finish, here is the most fundamental reason which made me abstain: All, author and readers of this article, we lived our adolescence with secret gardens[15]. They dealt quite often with our transgressions, often benign, but sometimes also very serious. And many have straightened up and continued sociable lives, without their parents ever knowing anything about it. So why doubt Jason and infantilize him? I am a psychotherapist, not a police officer!!

About confidentiality

In individual psychotherapy, adolescents have the right to total confidentiality, which I discuss with their and their parents before starting my work. I therefore convey to the family that I recognize their right to privacy, autonomy of thought, non-dependence and differentiation from their parents. I work this way with everyone, even with those who are still afraid of taking off and still tell (almost) everything to their parents.

Meetings with the parents therefore take place, in the presence of the adolescent as a rule, but that is to say that the therapy is going on and that I cannot say anything about it. There are still many themes that parents want to talk about, with a little bit of rivalry and criticism regularly to make me understand that the teenager is not doing so well, that it is hard to live at home and that he can manipulate me. …but at least the parents do not feel neglected.

Strong respect for confidentiality is often an essential condition for the adolescent to dare to engage his most personal questions when he wants to! This respect has nothing to do with any position of approval if not complicity in the transgressions that the adolescent would come to tell. This too must be made clear to him: he comes to work with me to reflect, to feel happy to live and to make wise choices. His transgressions are part of development, but what he says about them is an object of reflection and not of shared pleasure!

 And if they are really anti-social and destructive transgressions, against the fundamental Prohibitions, I must tell him that it is wrong, ask him to give it up and work with him to make it happen.

Does this specific part of the work include that the therapist must ignore this precious value of confidentiality? Certainly not ipso facto! Three conditions must be met to go beyond:

---- The therapist believes that by his transgressive or dangerous behaviour, the young person is the source of a serious and close danger, to others or to himself.

Estimate made mostly from a dialogue with his young client; sometimes, concerns expressed by third parties are added to as well as the fruit of the therapist's observations (for example perception of a suicidal atmosphere, of strong guilt with inhibition…)

---- The close threat of great danger cannot be reduced significantly from the thinking carried out during therapy.

 ---- Finally, the therapist thinks that the people or institutions that he will alert will be more effective than him and therefore ward off the threat. It’s not a matter of running a hot potato just for the sake of taking shelter

Availability of the therapist to meet the adolescent's needs

Long live non-resigning generosity! I remember that not even forty years ago we unhesitatingly had our patients for sessions three or four times a week. Evelyne Kestemberg, a well-known French adolescent therapist, used to say ; In the course of an afternoon of consultations with teenagers, you always have to leave some free time for unscheduled visits. Don’t  imagine they are all going to fit neatly into the slots arranged by adults, like little soldiers all in a row. You have to give them much more time when they are going through more intense crises and you must always be flexible.

Nonetheless, the therapist should not feel forced to respond systematically  to what the teenager claims  as urgent needs. He can always - indeed, he must - keep to a set schedule, while remaining receptive to the ups and downs in the life of his young patient. A really interesting aspect is the combination of ritualization (that in most cases includes physical face-to-face meetings) and more unpredictable moments, when the therapist has to be immediately responsive to the intense experiences  the patient is going through.

Notes

[1]  Unlike “physical” sessions, most of the time a webcam session involves two faces close up on the screen. This means that the little facial expressions, moods and body language of the interlocutors is transmitted and seen with implacable intensity!

[N.B. To describe normal sessions that involve actual physical presence, I will use interchangeably the terms embodied, real live or IRL (in the real life)]. 

[2]  All this in a young person not at all hysterical and not in any way playing hide-and-seek with me! I felt he was overwhelmed by a paralyzing sense of shame and guilt!

[3] I draw a distinction between quite commonplace sex game of the kind that occurs between children, including siblings and real fraternal incest, based on structural criteria to which I refer here. Read further, in the discussion, the paragraph  “Incest in siblings” 

[4] The first time, he initially balked at the word “sexual”. He asked me to wait and got up to go and make sure the door of his room was closed. The use of the webcam raises in a new form the problem of intimacy and the possibility of “spies” listening in one of the rooms in the house, This also involves what is done with the written text: is it simply a case of “now you see it, now you don’t”, or is it printed? These are real concerns that can arise and complicate the desire to free oneself at work at Jason's. 

[5] J.-Y. Hayez, La sexualité des enfants,  Paris : Odile Jacob, 2004.

[6] Jason is from a Christian background. The text of the Gospel doesn’t take away from the fact that incest is wrong, but it reminds us of the universality of the fault, the fall in our human condition. 

[7]   I still agree with all the suggestions I made in the e-mail except this: the real shared responsibility, is 100/100/100 %. Each party is also 100 % responsible (the third party are the parents, for their lack of vigilance!) 

[8] In my heart I thought that he was probably still feeling bad because he hadn’t yet told the most difficult part…. but I did not tell him about this idea, which could have blocked him more than stimulated him ...

[9]  I imagine that the opposite of basic is penetration (in all its forms), but I didn’t ask him at the time. 

[10]  I could find nothing better on the spur of the moment than this poor example that gives Jason alone the blame for what is a very grave transgression. With hindsight, I could have found a more 'collective' example with less irreversible consequences. In my counter transfer, I was probably creating a clumsy form of rivalry with Jason's father: "I know things about your son... I can't tell you what... and the only thing you should do is have compassion for him!" 

[11] During the following session, I didn’t refer to the fact that he had missed the appointment, except off-the-cuff during our discussion. He replied, equally off-the-cuff, that it was because he felt inhibited and that he didn’t want to face me with nothing to say. And as in addition he knew the time of the next appointment, he didn’t see the point of saying anything else. I just commented: “OK”.

[12] A more modern version of Little Hans, so dear to S. Freud. There can be no doubt about it, horses and their sexual organs still fascinate children...

[13] For more détails, consulte the book J.-Y. Hayez,  La sexualité des enfants, Paris : Odile Jacob, 2004 ( p. 146 et sq.)

[14]Fusion must be understood in two directions: very intense close, con - fusion of bodies and beings, and also: torrid, boiling, very hot aspect.. 

[15] I discuss it in the book "la parole de l’enfant en souffrance" written with E. de Becker (Paris : Dunod 2010, p. 249 and sq.) 

Summary: This single case study describes important moments in the individual psychotherapy of Jason, an adolescent disturbed by long-term incest carried out with his willing sister, incest completed for two years ago. The study focuses especially on the use, during therapy, of an Internet voicemail. The author then discusses some clinical and ethical aspects related to the specificity of the case: Internet utility, confidentiality, meaning of sexual activities in siblings, etc. 

Key words:  incest among siblings, sex game among siblings, neurotic guilt in an adolescent, online psychotherapy, psychotherapy via webcam