Psychiatrists are increasingly incorporating advances in communications into their clinical practices. Skype is an example of one treatment medium which has been adopted by many practitioners and has been recognised for its capacity to provide enhanced convenience, to increase access for patients and to allow for continuity of care.^{Reference Hoffman1} Despite lingering questions regarding the Health Insurance Portability and Accountability Act 1996 (HIPPA) compliance and licensure requirements, reports indicate that a substantial number of mental health professionals are currently using non-traditional communication media in their practices.^{Reference Jacobsen and Kohout2}

The increasing utilisation of voice-over-internet methods such as Skype by mental health providers has resulted in the emergence of novel therapeutic matrices with attendant challenges and opportunities. In this letter, I describe how some of the features of Skype, and video conferencing more generally, offer a unique opportunity to address therapeutically a fundamental component of the narcissistic disturbances.

Disturbances in the experience of the self are central to narcissistic vulnerabilities. Kohout believed that parental empathic failures resulted in a child’s inability to successfully modulate fundamental self-functions including self-esteem and mood and to be dependent on others (self-objects) to mediate these functions.^{Reference Baker and Baker3} Kohout thought that psychotherapeutic treatment of such narcissistic disturbances required therapeutically focusing attention on empathy and in particular on analysing and working through empathic failures that occurred between the therapist and patient over the course of treatment.

Skype and similar video conferencing technologies present opportunities to explore empathy, connection, attunement and their vicissitudes. In traditional therapy, empathic failures that inevitably arose over the course of treatment - the therapist being late or not responding to a comment in an empathic way - tended to be addressed as they materialised. However, the intrinsic features of video conferencing such as connection strength, the complexities involved with consistently achieving direct eye contact, not infrequent problems with audio and visual components resulting in less than optimal images, missed words and delays together create empathic failures and misattunements in the relational field and thrust such issues, particularly disconnects, to the forefront of treatment.

In my practice I have found that such actualities of Skype serve as valuable opportunities to explore these technologically facilitated empathic mismatches. Early in treatment, such Skype-associated empathic divergences need to be addressed at a manifest level such that a complaint about sound quality should result in a collaborative attempt to remedy the audio issue. Demonstrating to the patient one’s concern about the connection and willingness to help remedy it demonstrates responsiveness. Later in treatment, patients’ feelings about the disconnect can be more fully explored, for instance ‘How did you feel when you could not hear me?’ In this way, a progressive approach involving early responsiveness to, and later further discussion of, technologically facilitated empathic mismatches can help necessary work on patients’ underlying narcissistic issues.