Month: April 2021

For Some Psychotherapists, the Work Has Always Been Virtual

Posted on by Melonie Bell

A therapist shares knowledge gained from two decades of teaching online.

  • Familiarity with the experience of online therapy can help ameliorate stress, both on therapists and our patients.
  • Online learning opportunities abound for mental health professionals, particularly in this era.
  • The ongoing stressors of the pandemic will affect individuals, couples, and families differently.

It has been a difficult year for patients and psychotherapists everywhere. As all therapeutic work moved online, my colleagues at the International Psychotherapy Institute and I had one advantage: We have been at a distance-learning institution for 25 years. As a result, we were ready when suddenly everything was forced onto online platforms. In particular, we were prepared to treat couples and families negatively affected by lockdowns, and to help our students do the same.

Even as vaccines offer a light at the end of the tunnel, online therapy and training are not going away. Here’s what I think therapists can learn from our experience:

Online therapy is better than ever. Our initial close partnership with the Tavistock Clinic, the Tavistock Institute for Marital Studies (now called Tavistock Relationships), and Westminster College in Salt Lake City, Utah, used early shaky technology and unreliable internet to establish distance training. At first, all of our students had to be in the same room at one of four locations; that was all the platforms would support. Over time, we adapted to each iteration of improving technology, and eventually we could reach people on their own computers, beginning about 15 years ago. We have now been conducting online trainings and supervision in China and Russia for a decade, even as the technology has continued to improve dramatically.

Opportunities for online training have grown enormously in the pandemic. A real paradox, for us, is that our training programs have grown enormously. Through offering Town Hall meetings and online trainings, we have colleagues and students joining us at IPI from around the world in much larger numbers, and despite the time zone differences. The need to put all our conferences online has meant that people could come to courses and conferences without the expensive need to travel. I do miss seeing my friends and colleagues at in-person conferences, which IPI has always held four or five times a year. But I am reaching and interacting with more people from all over – throughout the U.S. and Canada, India, Pakistan, Europe, the Americas, Australia and New Zealand, China, Romania, and Russia. For some in India, China, and Australia, our programs happen in the middle of the night, but still they come.

Online therapy allows for international insight: you’re not alone, and neither are your patients. Because I work with therapists worldwide, especially in China and Russia, I could see how much the pandemic affected couples and families everywhere, not just in the United States. Some were positively affected when they had more time together, and solved the problems of quarantine and risk reduction together. But as we all know, other couples and families were adversely affected, with more conflict while confined together in marriages that went from contentious to unbearable familiarity, and often then to an urgent need to divorce.

A spike in divorce rates, for example, was reported in Wuhan, China from the outset of the pandemic. Couples that had maintained their marriages by spending very little time at home together, usually with one member of a couple working in another city or traveling for work, were now locked in together. Some were suddenly much happier together. But many found themselves with a new and unbearable closeness, and their therapists had a new problem to deal with.

Some takeaways from our experience. Patients—especially couples—have had increased need this year, which has kept me and my colleagues even busier than usual. For therapists still learning the ropes of online appointments, here are a few ways to support the couples you work with:

  • We are all experiencing “PTSE” – Pandemic Traumatic Stress Experience. It’s not a disease. It is not PTSD. It is a shared experience of stress common to therapists and patients alike.
  • Acknowledge the differences in the way of working online that color the therapy.
  • Look for analogous differences in patients’ and couples’ lives that are highlighted by the experience in online couple therapy.
  • Connect their distress as a couple or family with the wider distress that we are all living with – our shared PTSE.

Thankfully, my colleagues and I are surviving the covid pandemic. Though we miss our freedom, we have been able to use our expertise to benefit both our students and patients in the newly virtual world. We’ll be glad to be able to meet patients in the office again and to meet each other in person at our conferences, but we all know that our ways of conducting therapy and training will never be the same again.

 

David Scharff, M.D., is Clinical Professor of Psychiatry at the Uniformed Services University of the Health Sciences, as well as at Georgetown University. He is also Co-Founder and Former Director of the International Psychotherapy Institute; Chair of the International Psychoanalytic Association’s Committee on Family and Couple Psychoanalysis;  Co-Chair, APsaA Advisory Committee on COVID-19, and editor-in-chief of Psychoanalysis and Psychotherapy in China. He directs training programs in analytic couple and family therapy in Beijing and Moscow.

How the Light Gets In: Contemporary Understanding and Treatment of Trauma

Posted on by Melonie Bell

 A lecture-discussion by Dominique Scarfone

 Today is Saturday April, 10, 2021, and I am at the IPI Saturday morning guest lecture by Dominic Scarfone. I am sitting here in my Zoom window along with clinician colleagues from thirteen countries (Austria, Canada, India, Iran, Japan, Macao, Mexico, Netherlands, New Zealand, Panama, Phillipines, Romania, and South Africa) and twenty-five US states. The IPI Director has explained the use of technology so that we know how to introduce our questions and comments into the large group discussion of the ideas presented to us in the lecture “Trauma, Subjectivity, Subjectality.” Dominique Scarfone, a Montreal psychoanalyst, professor, and author of The Unpast and Laplanche, is talking about these ideas developed from those of the French psychoanalyst Laplanche. Since most of us are more familiar with Anglophone psychoanalysis, we’re looking to Scarfone for his translation of the French way of thinking about the impact of trauma upon the infant’s developing body and mind and subjectivity. Later we’ll hear about subjectality.

Scarfone tells us that, when trauma is the focus, psychoanalysts tend to see it as an exceptional problem as if it calls for something other than the foundational method of psychoanalysis. This is not justified. In his view, trauma is a general part of the impact of the other on the self and falls along a continuum. To him, trauma is normally, inextricably entwined in psychic life, as the infant subject confronts the other, and in particular has to deal with the impact of the care-giving adult’s infantile unconscious sexuality.  The theories of attachment or mentalization do not take sufficient account of the enigma that the adult’s infantile unconscious sexuality poses for the infant mind.  When the infant mind cannot articulate what is going on but can only register it, the experience creates a primordial split between what can be held in mind and what cannot.  This is due to implantation of the traumatic sexual enigma stuck in the infant mind like a foreign body, an experience the infant has to decode or translate — an effort which will be only partially successful.   When the sexual enigma is accompanied by violent passion, the translation effort is compromised and impeded what Laplanche calls intromission, and Scarfone calls intrusion.  The balance between implantation and intromission, is determined by the context of relationship with the other.

The mother who provides sensitive care for her baby always shows some deviation from the provision of care into the realm of sexuality. Lest this sound too abstract, Scarfone gives us an example.  Imagine the parent at bath-time, pretending to be a monster coming to eat the child up.  The parent communicates intense oral desires, but this is play, the infant enjoys the pretense, and the cannibalism doesn’t happen.  The mother who puts the baby to the breast may have sexual feelings and responses from the nipple stimulation.  All this is in the realm of ordinary parenting behavior.  In Scarfone’s view, unlike Freud’s view of psychosexual development, the infant is not sexually endowed at birth.  (I would put more value on the infant’s active pleasure-seeking, sucking and caressing, but that is not Scarfone’s focus).  He redefines infantile sexuality as being evoked in a libidinal and inviting interaction with the other. The child registers the various forays from the other, and stores them for future understanding.

The human context that the various others caring for the child provide is unpredictable. Attempts at consistency and reliability are never perfect – which is a challenge for the infant, but has an upside, since surprise and novelty stimulate adaptation and growth of individuality.  Scarfone agrees that the infant and mother work together to create a symmetrical attachment relationship, but believes that, since the powerful adult is endowed with sexual desire and the infant is not, this part of the mother-infant relationship is asymmetrical.  When an adult’s caring for an infant is infused with the exertion of power and mastery, the child, who thereby is required to submit to the desires of the other, suffers a greater amount of trauma than usual from the encounter with the other. The trauma is compounded because the infant (and later the child in that situation) is in a helpless state of mind, unable to put words to events and symbolize what has happened.

The normal development of our subjectivity is subject to the history that came before us, our sexual drive, unconscious elements all around us, our suffering, and the estrangement we have experienced.   The subject should be the center of action. But when treated as a thing, the person loses the sense of subjectivity. The child may be diminished by the shame of her helplessness or may respond by imagining she is special in order to preserve her dignity and elevate her helpless masochistic surrender to a triumph. Traumatized people who were so objectified may join others with similar feelings to form a compact mass for support, but are then subjected to the common opinion, and find themselves again victims of abuse of their own making.  It is difficult for them to recover their subjectivity.  Now we find out the meaning of subjectality – the taking back of one’s subjectivity and having one’s own opinions, desires and choices.

We are fascinated by Scarfone’s way of thinking, puzzled, intrigued, struggling a bit, and inspired.  We listen; we compare and contrast the French ideas to those of Freud and Winnicott; and we debate with him directly.  The fabric of our thinking has been torn by our contact with the other.  In the ensuing small affective learning groups, the translation and integration continue letting the light in through the cracks.

Jill Scharff