184.108.40.206.2.A case of incest brother sister treated by therapy online
The main purpose of this paper is not to present all the different aspects of the individual psychotherapy applied in the case of Jérémie ( almost 17 years of age ), with the different technical, ethical and confidentiality issues that it raised, but rather to demonstrate how the use of the Internet was useful in enabling Jérémie and myself very quickly to come to terms with and overcome what was a very delicate phase.
Jérémie’s parents separated when he was five years old. Since then, he lived mainly with his mother, in a small rural village, and he has had regular conflict-free contact with his father. He has one sister, Joanna, who is one year younger than himself, and he gets on well with her. He is of average to above-average intelligence. He attends a mainstream school. His academic results are mediocre ( a combination of laziness and passivity along with a lack of motivation and, as I gradually discovered, a number of secret preoccupations that were a distraction to him )
Since he was 15 and a half, Jérémie 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 four months when his father phoned me to tell me that he was still using the Internet a lot, but, he said : « that’s not the problem any more » Something was wrong with Jérémie. He was sullen, withdrawn and increasingly lackadaisical. We therefore resumed the therapy. We still had a good relationship, but it was a conventional and evasive relationship that focused on fairly general subjects ( school, young people, the Internet, etc. )
The case and the critical sessions of psychotherapy
Overwhelmed by fear of death
Three weeks later, his father called me on the phone. He was very worried because Jérémie was getting worse. He had an overwhelming fear of death that made his life a misery. I gave him a quick appointment during which I told Jérémie about the phone call from his father ( who had not concealed this from him ) He told me that it was true that he was afraid ( how it was so bad that he couldn’t keep up with his schoolwork and how he would feel his pulse to check that he was still alive ) He told me that he couldn’t connect this recurrence to any specific experience or to any change in relationships or to any new questions he had recently come up with about life. I told him that what he said made me think 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 see what he could find for next time.
Because he lived over a hundred kilometres away and it was urgent and because we are both interested in the Internet, I suggested we do the next session five days later over the Internet and MSN, 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, we turned on our webcam and our microphones and communicated via MSN. Jérémie 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 himself for something and that he was perhaps punishing himself. I discerned right away that he was very ill at ease, sad and ashamed. He told me he had something very serious to tell me, but that he would never dare say what it was, as he was really too ashamed. I took this seriously and at the same time gave him some general encouragement (« Try, Jérémie. It’s important for you to express yourself ») Then, as he was inhibited, I suggested, half joking, a few specific ideas which by intuition I felt were probably not pertinent to him  (« What ! Are you telling me that you have these really sadistic fantasies when you wank it off ? Or do you sometimes drink your piss ? ») That made him laugh ( well, a little ), and then he gave me an answer that I understood as « If that was all it was ! » He kept saying that he felt too ashamed and then he said 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 said it . So I agreed to turn off the video function and cut off the sound from him to me. Jérémie could still hear me, but the writing appeared gradually on my screen, like in an ordinary Internet chat session. 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 to tell me that you think is so serious? Have you killed somebody? Have you sex with your mother? » J : « It’s almost that. » Dr H : « Come on, Jérémie, explain » Then, spurred on by my reactions and my specific questions, he wrote in brief sentences that for seven years he had had incestuous relations with his sister Joanna . He felt utterly ashamed, and he was convinced that he was totally to blame for it, because he was one year older than her. However, they both took the initiative. There was no constraint. Sometimes he had the idea, and sometimes it was her. It was he who decided to stop when he was about 14 « because it was going too far » ( incipient penetration and ejaculations - « three drops, no more », he added, quite ingenuous ) 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 at their father’s house or mother’s house, and they always kept it a secret.
As he was explaining how this had gradually developed, I mentioned that in my view this sex-activities had gradually changed from being banal sexual games and had become incest because for a very long time they had been like partners and that they had been each other’s only company and because, as Jérémie 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 fortnight after he found out that his sister was not in good mental health and that she herself had consulted a psychotherapist (« That destroyed her too, and I was to blame for everything », he said : « But she says that it’s not because of that. We talk a little about it, but she says that it hasn’t affected her ... that she remembers it like a nice dream »)
Of course, this description didn’t come out all in one go. Once Jérémie started writing, short phrases came up in quick succession, some of them spontaneously, like a confession that has to be vomited out once it has started, and some of them 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 had the feeling that Jérémie had just about said everything he had to say in this first written session, so I asked him to switch the sound and video functions 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 Jérémie’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
We then spoke for some time during the following part of the session.
◊ - First of all, we engaged in a little ritual. I asked him to repeat after me, bit by bit, the following sentence : « Dr Hayez/with my sister/I engaged in/heavy/sexual activity/for several years. » Although he was initially somewhat taken aback and embarrassed, Jérémie quickly went along with this ritual , then at my prompting he repeated the whole sentence on his own, and he was relieved. It was just after this ritual that 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 say anything he hadn't yet said, but I simply collated snippets of his own language and made the text into a unified whole. The text is not of course of trivial and it strikes at the heart of the confession he was brave enough to make, but I get the impression that this helped us save time and that it was at this point that he understood that I still wanted to listen to him and that I still had respect for him, despite the fact that he had admitted and that I had heard the full extent of his « crime »
◊ - We then talked about the nature and meaning of what he had done ( incest or simply sexual game ) and the responsibilities involved. Among other things, I suggested he should get the book I had written about child sexuality  and read what I said about sexual activities between brothers and sisters and then discuss it with me.
◊ - Finally, we talked about the seriousness of his actions, his self-esteem and any esteem that I might still have for him. I didn’t want to reassure him too quickly about this, but rather I wanted to listen first to what he had to say. After that, I reminded him about the episode in the Gospel of John  when Jesus spoke about the woman who had committed adultery : « He that is without sin among you, let him first cast a stone at her [ to stone her ] … [they] went out one by one, beginning at the eldest, even unto the last » . He also asked me if it was just in the context of my work that I said that 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.
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 about Jérémie quite often and after going over things in my mind for quite some time, on Sunday evening I sent him an e-mail ( see annex 1 ) When I read it now, I still agree with all the suggestions I made to him, except the first : if there is any shared responsibility, it is 33/33/33 or, to be more precise, each party is also 100 % responsible ( the third party are the parents, for their lack of vigilance !)
On Monday evening at about 5 o’clock, Jérémie 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, which he said he agreed with, but he said that there were some points he wanted to discuss again. I told him that if that was the case it was probably because there were still some serious things to be said in the 20 % of issues that we had not yet broached. He agreed and asked me if he could talk to me sooner, but « like the last time, because I couldn’t look you in the face » I gave him an appointment by webcam for the same evening at half past eight.
Following webcam session
Monday 8.30 p.m.: Jérémie 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.
◊ - Generally, he was sleeping very badly ( he fell asleep at about 2 o’clock in the morning ), and he was still very anxious. He asked me to give him medicine to help him, but he knew the name of the medicine and had direct access to it, because his father is a chemist. We put together a treatment based on benzodiazepines, provisionally and subject to further adjustments and prescriptions.
◊ - He told me more about his feelings and the ideas that were then going through his head about what had happened, 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 talk about what had been going on to the (female) psychologist she would be going to see and that the therapist would then tell her mother ( she is a friend of her mother’s ) This could mean for him a « terrible tongue-lashing » He would get all the blame, not only because he is the elder brother, but also because, as he now admits, his sister didn’t always consent - « But neither did I ... »
Of course, I promised to discuss this with him again. At that point, however, I put forward my new hypothesis : that is, I said I had made a mistake in my e-mail when I assessed the responsibility as 50/50, whereas it was rather 33/33/33. I got him thinking about the third 33% ( lack of vigilance on the part of the parents ), and as he couldn’t find the solution right away, I said I would leave it as an enigma for him to think about. 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 about some aspects of his incest in more detail. I told him that he was probably still feeling bad because he hadn’t yet told me the most difficult part. He claimed that he couldn’t remember right away, and then he said « Oh yeah, it’s coming back »
I tried to get him to describe what happened the first time. Initially he could just remember one thing : 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 silence, and no words were used to refer to the parts of the body or to what they were doing. He told me once again that it was « basic  : 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 that that was the way it was with 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 told me that he was hurt by the words « show m », because that made it look as if he was giving orders.
Time went by, and it was soon time to sign off. I told him that we still had work to do and that we needed some more actual details for him to feel more free inside. He replied that he didn’t have the courage to tell me face to face, but that 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.
I sent him a second e-mail on Tuesday morning (see annex 2)
On Tuesday evening, his 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 with us and that 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 at 11 o’clock. I listened as he explained to me once again how worried they were as parents. After listening, I replied that the situation was similar to the example that I would give him, but that of course the example does not concern Jérémie : « 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 is 17 years old ? » . Based on this hypothetical situation, I discussed a number of ideas with his father connected with tolerance and support. I told him that my feeling was that it would be better for Jérémie 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 for him to say to his son at some opportune moment : « Children sometimes do things that are really wrong, but real parents can listen and forgive»
On Wednesday evening, Jérémie missed his appointment and didn’t reply to a new 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, especially surrounding the question of « force or no force » 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 explain some of these thoughts and to remind him that he could talk at his own pace. However, I eventually decided to let him see that he could win and that I wouldn’t insist or try to pressure him. I decided to wait until Friday, when we would have the next session, except if any emergencies came up during the week.
I felt that the fact that he missed his appointment was very good for Jérémie ... 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 see me .
. Emerging from the crisis
On Friday afternoon, his mother phoned me to ask if Jérémie had an appointment for that evening. I said that he had, and that he could either come to my office or use the webcam. For my part, I would agree to either arrangement.
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 ( that definitely suited him !) He smiled from time to time, breaking the dialogue that I purposely tried to « lighten up » Now and again, he would look furtively right at the camera ( so he could see that he was looking at me straight in the eye ), and a couple of times I said : « Come on, Jérémie, look at me ! », and he had the courage to look me in the eye for a few moments. I still feel that this kind of prompting was good for him. When I asked 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 wanted to talk to me again about my e-mail from Tuesday, about what he saw as the true and the false bits. I wrote : « Come on, man, I’m listening », then I put a smiley . He once again stressed that he had never physically forced his sister. Of course, convincing me - and perhaps convincing himself - was one of his most important objectives. The image he had of himself would have been seriously dented if he found himself being accused not only of being very sexually precocious but also of being an abuser! When either of them didn’t want to, whoever did used charm and said « please », and this often got results. I told him that if that was the case, 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 the nature of their relationship, which consisted of much more than simple sexual frolicking, not the mechanics of their relations.
He then talked to me about the fact 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 and that by giving himself all the blame he could be showing what was tantamount to male chauvinist thinking and culture, as if girls were brainless creatures. This made him smile. I asked him if he had solved the enigma of the three 33%. No, he hadn’t. We talked a little about it again. He could of course find two of the three parties ( his sister and himself ), but he still couldn’t work out the third element ( his parents’ lack of vigilance ) I asked him to keep searching.
It was then that he focused the discussion on what had triggered his sexual desire for his sister when he was seven years old. He told me that it was something he had seen that then became a picture in his mind that had often come back to him from that very early age. For him, that 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 to me a beautiful wildly primitive scene : his sister and he had seen horses mating  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 the word « saillie » (mating) wrong ; he wrote « sallie » ( with undertones of dirtiness ) and then « saïe » ( that may suggest the idea of pain ) He added that he could never spell the word « saillie » properly . The point is that many children of his age entertain dirty or sadistic ideas about the primeval urge behind the sexual act, and he had had unnatural relations with his sister. From a therapist’s standpoint, the serendipity of 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 churlish at that particular juncture )
I asked him if at that time he had any intuition that what he had witnessed was something to do with the transmission of life or if at that point he already knew something about parental sexuality and where babies come from. He said « No »
He said no, but he wanted to imitate with his sister that powerful sense of oneness between animals, and it was this imitation that he felt guilty about. He hadn’t yet told me exactly how they had gone about it, and I told him that in future sessions he would have to give me more details, to get more off his chest. 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 Jérémie that I was worried about his sister’s possible psychological health. I told him that I didn’t believe that it was as easy for her to live with it as she claimed. I told Jérémie once again that 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. I replied that I would be only too pleased if she did.
At one point during the session, we discussed the sense of inner release that he now felt more strongly. Nonetheless, I asked him to get a sheet of paper and got him to make a graph :
- On the x-axis, I asked him to put on a scale from 0 to 100% how difficult he felt it was to tell me certain things : from relatively difficult, i.e. a source (++) of shame and guilt, to very difficult (++++)
- On the y-axis, I asked him to mark off three levels ( 70 %, 90 % and 100 % ) From these, I asked him to draw a horizontal line, and I asked him to write the three phrases below. I then asked him to hatch the areas that I represented as hatched, with a margin with question marks. I then discussed the table with him.
◊ - This is how I represent his striving after an inner release and reconciliation. The hatched rectangle is the possible intensity of the release. I don’t know exactly where it is on the x-axis, but I guess he’s already come a long way ( i.e. at least 80 % or even more )
◊ - On the y-axis, the fact that he has already expressed himself to me as a representative of the human community is in itself very positive, but I imagine that his inner release will further increase if one day he tells his father about it and asks forgiveness. However, his sister also has to agree to take this step, preferably together. The father, who is separated from his wife and doesn’t get on well with her, might agree to keep the secret. But the ideal situation would be if one day the father and the mother could know about it, react and extend their forgiveness ( 100% on the y-axis )
I noted Jérémie’s reaction to the x-axis (« I feel much more of a release than you think ») and to the y-axis (« Woah ! » then « Woah! Hold on ! ») I told him that I would never put pressure on him to go faster or pressure him into taking decisions in this regard, but I told him that I couldn’t help but think that if one day he could do it it would be better.
□ - The session ended. The Easter holidays were coming up, and I wouldn’t see him for ten days. I told him that he could write to me if he wanted to ( and I gave him my holiday address ) I then made the next appointment for a live session.
The rest of the therapy is not uninteresting, but I think I have told you enough to prove my point, that is, that the Internet was useful in this case.
One final point. I know that Jérémie keeps Chilean degus in his room and that he’s very fond of them. I know this because during a webcam session I heard a noise and asked him what it was. He told me about the degus and showed me the cage and one of these little animals.
In this context, I think of Dolto and the importance she gave to direct and symbolic payment of her sessions by her young patients. Given that to a modest degree I have become intimately involved in Jérémie’s life ( I was familiar with his room, etc.), I decided on a plan: towards the end of the therapy or the first phase of the therapy, I would ask him to give me one of his favourite degus, along with a cage and instructions on what to do with it. I thought about finding a place for it with some children or in our waiting room. I was thinking that he owed me that and that anyway that wouldn’t be a problem. He would be quite pleased at the idea of this living, real and symbolic representation of a kind of link between him and me.
I will confine myself to discussing the impact of the Internet on this phase of Jérémie's therapy.
- ---- Rightly or wrongly, I was convinced that if we had had only physical meetings, because Jérémie was paralysed by inhibitions it would have taken months for him to pluck up the courage to talk to me about the incest, or he might not even have ever talked about it. 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 that allows many people very quickly, once a sense of trust has been created, to feel comfortable enough to express many intimate things. Sometimes strict anonymity makes it easier to talk about oneself ( sometimes this is not the case when the chatters know each other ) However, whether communication be via a webcam or a simple written dialogue, without any visual implications, what is said is always coloured by the following paradox : the impression of tremendous closeness, warmth and encouragement ( for example, we could see each other close-up attentively listening to each other and our voices resonated ), and, what's more, there is the certainty of total protection from any intrusion by the other person.
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 is there to protect the penitent from the thunderbolts he imagines may be hurled down by the gods. And then the pattern of holes in the screen creates the same impression of a moving face. Moreover, an experienced father confessor is supposed to be empathetic and open ... just like a psychiatrist.
In my notes on the sessions, I hypothesized that when Jérémie was looking straight into his webcam he was looking me in the eye. This is actually what he appeared to want to do whenever he became aware that I was looking at him too ( because my face was displayed on his screen )
Is that what we do at these times : looking at each other, divining the person behind the image ? I think I can answer in the affirmative: all webcam users whatever the circumstances ( whether it be festive, informal, etc.) confirm their impression that they are not in fact navigating in a virtual world, but they are genuinely in contact with real people who communicate by electronic means.
Does this form of expression have the same power to offer inner release as the physical meeting of two people, i.e. the therapist and the patient ? I would say more or less. It is even an accelerated release, but it is, I feel, only definitive if it is followed by one or more physical encounters of the two people concerned. They can then see whether they were under an illusion when they were talking on the web. This is the ultimate test. It applies the indelible seal of reality. It is only then that each side dares to open up to the other person ( spiritually and physically ), giving him something of himself, risking the unpredictability of the reaction of the other person who is quite close. The breath of life then envelops both of them and confirms - in a good case scenario - that what they experienced on the net was not an illusion. Therefore, even for patients who live very far away, it is essential to alternate between webcam sessions and live sessions, even if the alternation cannot always be perfectly coordinated (1/1)
Two more advantages of using the Internet
- ---- An encounter with a teenager in one of his favourite worlds : Although both our computers were on, symbolically it was I rather than he who had stepped into a different world, a territory that is highly favoured by teenagers. I had gone to visit Jérémie, and he appreciated that. This increased his desire to confide in me, as I could show that I was close to him . Not all adolescents would have been so appreciative! This is a possibility, therefore, that we should take the time to negotiate, on a case-by-case basis, and it should not be undertaken if the teenager regards it as an intrusion of his privacy. Moreover, even with adolescents who accept this communication, I don't think it is good to be too often hanging around their world. There's a need to alternate. Sometimes they too have to enter the adult world from time to time and think.
- ---Speed and flexibility as regards the scheduling of chat sessions : Combining e-mails and chat sessions ( written or audiovisual ) 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 his very intense, fluctuating and fast-moving emotional life. For example, I responded to the acute feeling of distress expressed by Jérémie on Monday by taking him by surprise and suggesting an appointment for the same evening. He probably felt that he was being taken very seriously, which was very positive for the quality of our relationship.
Nonetheless, the therapist should not feel obliged to respond to what the teenager sees as urgent needs, calls for help that are prompted more by attention-seeking than any tangible concerns. It is the professional himself who retains control of the process. 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. Being attentive to his deep emotions can certainly help him to open up the floodgates and to express deep-seated thoughts, feelings and issues. Also, inducing him to keep within the boundaries of the ritual of bilaterally agreed appointments can help him to savour more tranquil moments of reflection and to work more effectively on the principle of social reality. One 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 that the patient is going through.
- ---- Flexibility in the use of communication channels : In addition to straightforward face-to-face physical contact, written chat sessions that involve absolutely no visual contact and e-mails, there is a whole range of intermediate possibilities. I made use of these different degrees of contact according to the situation, letting myself be guided by Jérémie’s tolerance or
Rather than simply draw the conclusion that Jérémie’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, where 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? Perhaps, but might it not also be the case that this is done to create the impression ( or even the illusion ) that he is out of sight and therefore beyond judgment ? Here, in practical physical terms, it is not the same thing. It is Jérémie who sometimes decides that they should both go off-screen. But isn't that just another way of getting the same result ?
Nonetheless, when using this flexibility we must be prudent yet bold. The webcam sessions can never completely take the place of face-to-face encounters. After all, a face-to-face meeting is an irreplaceable human experience that involves the geographical proximity of two beings ( body and spirit ) who can see each other, dialogue and adapt to each other’s unrehearsed movements. 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. The teenager must be willing to take a risk and sit a few feet away from the therapist and then see for himself, as it were, in the flesh that instead of succumbing to the wrath of God, he receives kindness, friendship and forgiveness. Until such time as he has been through this real and symbolic experience, he will be beset by too many doubts.by my perception of what was best for him ( I sometimes insisted that we switch to a different level of contact )
- ---- Flexibility in the use of communication channels : In addition to straightforward face-to-face physical contact, written chat sessions that involve absolutely no visual contact and e-mails, there is a whole range of intermediate possibilities. I made use of these different degrees of contact according to the situation, letting myself be guided by Jérémie’s tolerance or
But the question may be asked : Must the therapist be so generously available to teenage patients ?
I rather think that the answer must be yes. It must be remembered that not even twenty years ago we unhesitatingly had our patients for sessions three or four times a week. Evelyne Kestemberg used to say that in the course of an afternoon of consultations with teenagers you always have to leave some free time for unscheduled visits and not imagine that 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. Of course, we shouldn’t feel that we have to be at their beck and call every time they come to see us with what may be a pressing or disguised need for affection or with what may be a rather hysterical bout of anguish. The therapist has to strike the right balance for each young patient and for each phase of the therapy.
Jeremie's feeling of shame
In the course of this series of exchanges with Jérémie, I came to appreciate intensely what it is to feel ashamed, to feel the sense of shame gradually emerging. The feeling of shame wells up when someone feels that he has not only transgressed, but that additionally and very specifically he has done something that is dirty, disgusting and degrading. An infantile sexual experience is often portrayed in this way by adults. This notion had been inculcated in Jérémie, and it caused his sense of shame coupled with guilt. Is a child therefore more predisposed to shame when he pictures his naked body doing things that are not very noble ( fondling a little girl, rather than « screwing » an older girl of 15 or 16 ) ? No doubt ! However, it may also be that he was concerned about the simple fact that they were naked, perhaps even without having any sexual intentions, at an age when they might be expected to have a sense of modesty. Does the Bible not teach that just after they committed the original sin Adam and Eve saw each other’s nakedness ( they were simply naked, without any suggestion of a sexual transgression ) and they were ashamed ?
In any case, that is the kind of shame that Jérémie felt, with its highs and lows, when he came face-to-face with me. And in this context the Internet was a tremendous asset that enabled him to express it and come to terms with it at his own pace. Also, it enabled me to listen to him and observe him respectfully.
I believe that, even though it may appear to be inspired by the Coué method, one of the tentative steps I took at an early stage in the therapy ( having him repeat the phrase : « I engaged in sexual frolicking ») helped show him that I wasn’t going to fuel his sense of shame by pointing the finger at him, but rather that I wanted to relieve his anguish.
When we are ashamed, we are afraid of receiving reproof that makes us feel dirty or ridiculous because we are naked ( metaphorically or literally ) Indeed, Jérémie said of himself : « I felt I had been an idiot for long enough » ( he didn’t mention being bad )
When we feel guilty, we are afraid of the wrath of Zeus.
Jérémie was beset by these two feelings.
Why did I suggest that he read extracts of my book?
In addition to the fact that I felt that this might save time ( by getting a general overview of my thoughts on a particular subject ), it was also a way for him to find out what I thought « objectively », that is, without any reference to himself. He could read my thoughts as I communicated them in public. This would nip in the bud any notion that he may have had like « OK, he says that, but he’s just saying it for me, because it’s me, but he doesn’t really mean it »
 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 two people is transmitted and seen with implacable intensity!
[N.B. To describe normal sessions that involve actual physical presence, I will use interchangeably the terms in the flesh, physical, live or IRL (in the real life)].
 But having said that, maybe I’m being over-optimistic. Don’t we all have a dark side?
 All this in a young person who is not at all hysterical and who I don’t think was in any way playing hide-and-seek with me! I think he is really overwhelmed with a paralyzing sense of shame and guilt!
 He began by telling me that it was somewhere between the age of 10 and 13, but after I expressed surprise a number of times he eventually admitted that it was somewhere between the age of 7 and 14.
 I draw a distinction between commonplace sexual frolicking of the kind that occurs between many siblings and real fraternal incest, based on structural criteria to which I refer here. For more details, see J.-Y. Hayez, La sexualité des enfants, Odile Jacob, 2004, p. 146 et seq.
 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, sometimes unbeknownst to one of the two people and sometimes with the complicity of one of them. 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 that complicate the fantasies that more than likely were going through Jérémie’s mind at that time.
 J.-Y. Hayez, La sexualité des enfants, Odile Jacob, 2004.
 Jérémie is from a Christian background and attends Christian religious courses at school.
 This doesn’t take away from the fact that it’s wrong, but it reminds us of the universality of this in our human condition.
 I would imagine that the opposite of basic is penetration (in all its forms), but I didn’t ask him at the time.
 I could find nothing better on the spur of the moment than this poor example that gives Jérémie 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 countertransfer, I was probably creating a clumsy form of rivalry with Jérémie's father: "I know things about your son... I can't tell you what... and what you should do is have compassion for him!"
 During the session that followed, 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 said: “OK”.
 For those who are not into Internet chat sessions, if you write the symbol :-) at the end of a phrase, the other person will see this as a smiley, that is, a little round face like the sun, with two dots for the eyes and a smile.
 A more modern version of Little Hans. There can be no doubt about it, horses and their sexual organs still fascinate children...
 When one thinks about how teenagers spell during chat sessions, Jérémie’s moment of cognitive introspection is quite fascinating!
 Maybe I was sometimes too close, verging on the intrusive, as a result of which the boundaries of my role as a professional became very hazy. For example, I sent him an e-mail one Sunday evening, mixed up with my private e-mails. He was perhaps letting me know how he felt about this by mysteriously distancing himself from me during the week that followed.
 I should also mention the use of laptops and/or SMS or MMS.
 IRL = in the real life.
Annex 1 : My first e-mail (the first Sunday evening)
I was very touched by the courage and confidence you showed. Here are a few of my gut reactions :
- If things happened as you have explained, you are wrong to assume all responsibility. Given the fact that you are about the same age, it’s 50-50.
- Now that you have embarked on something and, what’s more, you have come quite some way towards freeing yourself from something that is very heavy on your mind, you have to go all the way. You have probably told me 80 % of the problem, so there is still 20 % - the most difficult bit, the things that make you even more ashamed ( for example, I am somewhat puzzled by the episode of your three drops of sperma ... Were you both in early puberty in the later years? Could she have got pregnant if you hadn’t stopped ? etc.)
- I understand that this is very heavy on your mind. Your experience is not something banal. It’s not just a case of a few weeks of sexual frolicking one hot summer. In fact, as young partners you were involved in a total and long-term relationship... If you read my book, you will see that what you did was probably somewhere « in between » real incest and sexual frolicking.
- Try to talk with your sister and look her in the eye ... It might be just for show that she says that she has come to terms with it. This is no more likely for her than it is 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 father, to safeguard your intimacy ( for example, to talk together about your relationship with your mother, which I know is problematic )
- Aside from your guilt, are you also afraid that your sister might let the cat out of the bag by going to see another psychiatrist ? If so, ask her, but of course you can’t make any demands.
- 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 Friday. Webcam or live ?
Annex 2 : My e-mail on Tuesday morning after the crisis session the evening before :
Here are a few suggestions for tomorrow:
- Work out the enigma of the 33/33/33 ( it’s not very complicated )
- Try to talk to your sister in depth ... I don’t think she would be prepared to reveal such intimate things to a psychologist who is her mother’s friend ... So she may still be « burdened down » ... Suggest to her again that she come to see me with you and find a pretext for coming ( after all, you’ve made hiding things from your parents an art form for years ) ... You’ll think of something... And this isn’t something wrong that you’re doing, it’s your RIGHT ... At your age, you’re entitled to keep some things private from your parents, so find some way so that they don’t ask questions.
- Don’t open the attached document until tomorrow at 5 p.m.
- Tomorrow and on Friday, we’ll work on the webcam, but next time I’d like us to have an IRL session .
The attached document:
For you to have real inner release, you’ll have to talk about the most difficult bit, i.e. the few remaining percentage points.
Here are some ideas that sprang to mind that might help :
- Talk about what really happened the first time or the last time ( Did you penetrate at all ? Didn’t you breach your sister’s hymen ?) Or talk about something that you are particularly ashamed of.
Was it really done in silence, or is it that you don’t like thinking about the words that were said or the kind of scenarios that you devised ?
The most difficult question, and one for which YOU have to be totally honest, is: How much of the time were you both consenting ? When did you not agree to it ? When did she not agree to it ? And when she didn’t agree to it, what percentage of the time did you feel like it and you forced her ? And how did you force her ?
All this isn’t easy, Jérémie, is it ? OK, but that’s what it will take to make your future life a success ...
Key words : INCEST BROTHER SISTER, incest among sibligs, sexplay among siblings, neurotic guilt in an adolescent, online psychotherapy, online therapy online, psychotherapy via webcam, therapy via webcam, psychotherapeutic use of Internet.