Ian Alger, MD

Since the 1960s, electronic recordings of both sound and pictures have been used in a wide variety of therapeutic approaches. In 1967, Peter Hogan, M.D., and I co-authored "The Use of Videotape Recordings in Conjoint Marital Therapy," published in The 

devoted an entire issue to "Studies in Self-Cognition: Techniques of Videotape Self-Observation in the Behavioral Sciences." In 1970, Milton M. Berger, M.D., edited the book 

Videotape Techniques in Psychiatric Training and Treatment

With video recordings, patients have the opportunity to follow Robert Burns' plea: "O wad some Power the giftie gie us, To see oursels as ithers see us!" Video playback has been used in individual therapy to explore emotional depths and identity issues, in marital therapy, in group therapy to improve and clarify communication, and to enhance behavior modification approaches.

One of the most important and influential collaborations in this early work with video in therapy was my relationship with Al Scheflen, M.D., a psychoanalyst and researcher in human communication. He, along with anthropologist Ray Birdwhistell, Ph.D., had done interesting work on the relationship between nonverbal communications, including facial expressions and postural behavior. In an observational research project, for example, they determined that there was a standard sequence of events during the "50-minute" American therapy hour. There was an "introductory period," then a segment when there was "resistance." Approximately 40 minutes into the session, the analyst would provide a signal -- most often a slight cough or a noticeable change in position. The session then moved into the "closure period," often with an interpretive final comment by the therapist. At times, only the movement was made and, since this made a slight sound, it would be enough to provide the signal that closure was imminent.

This work of Scheflen and Birdwhistell in videotaping ongoing therapy sessions was part of a larger interest in the importance of nonverbal communication and the signaling function in the way living space is designed and how furniture is located in a room.

This research encouraged many of us at the time to focus on the role of large and small movements as communication signals -- for example, with facial expressions and hand and leg movements. Such signals range from those to stop talking, to group movements that close the group to entry from an outsider when the group wants to maintain its boundary.

Videotape playback provided an extraordinarily sensitive instrument, allowing us to include these observations in therapy sessions with individuals, couples and groups. In the years that followed, a technique of family therapy was developed at the Ackerman Family Institute in New York that included videotaping with a "chorus" of therapists in another room viewing the live sessions. Either they would consult through phone connections to the therapy room, or the therapist being viewed would leave the room for periodic consultations with them.

In regard to the technique of "self-image confrontation," an experience from my childhood played an important role. When I was about 10 years old, I found a book on psychiatry in the living room of my uncle's farm and decided I wanted to become a psychiatrist. His brother had become a doctor, and this book was one of his old psychiatric texts.

As I thumbed through it, I was fascinated to see a series of photos of patients with mental disorders. I read that a psychiatrist had used these in a diagnostic test. If a patient looked through the pictures and responded to certain ones, the psychiatrist felt he could make a psychiatric diagnosis. He later described a test in which, by cutting a negative of a face vertically down the center into two halves and copying them, he was able to print a new photo of the face with two right sides and one with two left sides -- they looked amazingly different!

Years later, when I led a group at the American Group Psychotherapy Association and was demonstrating the use of video playback, I remembered that experience and thought of the idea of displaying right and left video split-image profiles and having the subject react to each side. In an adaptation of Gestalt therapy, I encouraged these "images" to join in conversation with me and then facilitated the two "sides" to speak with the patient and then with one another. In 1971, I made a video training tape entitled "Time-Mirror" and the following clinical vignette was used to demonstrate the "split-screen" technique.

"Susan," seated about three feet from a large television set, was watching a live close-up image of her face. I sat at her side as we conversed. After establishing a conversational relationship, I showed Susan a split-TV screen with her right and left profiles facing each other. I asked her to identify a name for each of the two profiles. She named one "Susan" and the other "Suzanne," explaining that "Susan" was like her, but "Suzanne" represented a very different person in many ways. As the session progressed, I maintained a conversation with "Susan-in-the-chair," "Susan" and "Suzanne." This technique was modeled after a Gestalt therapy in which different representations are identified as portraying different parts of the self. In the ensuing conversations, an evolving integration of the various feelings Susan had about her self (selves) developed.

Therapists now have a way, through immediate video replay, to "feed back" pertinent objective data from the therapy session to the patient so that the effect can be immediately reflected in the ongoing therapeutic process. In addition, because the data provided are equally available to individual patients, family members and therapist, a more egalitarian and collaborative relationship is encouraged.

Today, in addition to individual and group therapy, I specialize in marital and couples therapy. Recently, I received a call from a couple who asked me if they could see me for therapy using video playback. This was unheard of in the 1970s when I was experimenting with the therapeutic application of video. Today, the public's embrace of video can be measured by the ubiquitous home video stores and the development of digital video, which has made editing and the management of images almost magically available to everyone. Instant playback in sports has made everyone aware that additional information can be gained through replay and still-framing.

It is important to be aware of the groupings that are present in couples therapy. For example, in addition to the three individuals in the room, there also is a new therapeutic group of three as well as three dyads (the couple, wife and therapist, and husband and therapist). The video captures all the interactions among these three individuals and, in reviewing the action, each can comment on what they see and feel now and reveal feelings they had during the original interactions. At the actual time of the encounter, each person has some awareness of personal feelings and thoughts. On replay, there is not only an additional opportunity to reveal these personal feelings and observations, but also to discuss additional reactions and observations during the experience of the replay. Because all three people are in a collaborative reviewing mode, there is greater intimacy and less guarded revelation of feelings and reactions.

Current digital video equipment allows for easy placement in almost any therapy setting. Extra lighting is no longer necessary, and the small size of the digital camera makes the equipment less intrusive. Using two cameras has the advantage of more perspectives but requires a video mixer, and one wide-angle lens allows the couple and the therapist to be in the same picture. The presence of the therapist is extremely important in attempting to understand the verbal and nonverbal signals of the whole group, since the therapist is an active participant in the session. Because of this, it is made clear that any member of the group can call for a freeze-frame or a replay of a specific interaction.

If the couple has a video camera, they can run a tape at home during a period in which conflict often occurs, such as an argument about setting limits with children. Another valuable procedure is to give the videotape of a session to the couple to take home, with the assignment to watch it and choose a segment that represents an issue they would like to address in the next session. This is an economical approach as far as time is concerned and has the added advantage of being a collaborative task for the couple.

Communication occurs on the verbal cognitive level, on the emotional expressive level and on the behavioral level. Silence may be either deafening or golden; a glance can be tentative or scornful; a sigh may be resigned or impatient; a leg cross may erect a barrier to closeness; or an ankle crossed over the thigh may be defiant. By reviewing these actions, couples may gain a new awareness of meanings they have been reacting to unknowingly and anger that they have been unconsciously expressing. By making couples aware of these complex verbal and nonverbal communications, the therapist may facilitate more direct communication and encourage discussion of latent and simmering pain, anger, depression or resignation.

The video experience can provide all the participants with an opportunity to be immersed in an experience and, at the same time, be a conscious observer. The result can be an enhanced level of trust, understanding and empathy -- all factors in successfully achieving therapeutic goals.

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Nonverbal cues speak just as loudly as words. How can video be used to capture these subtle cues and help patients make progress in therapy?

Author | Ian Alger, MD

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