Howard Levine April 2024

Friday April 12, 2024

Today, IPI is back in its weekend conference location at the Rockville Hilton to study The Unstructured Unconscious and the Repressed Unconscious: A Clinical Paradigm for the 21st Century with Howard Levine as IPI’s distinguished guest. We haven’t been here since the weekend conference with Anne Alvarez in February of 2020.  The place feels so familiar, even the carpets are the same.  Friends I haven’t seen in four years. Students I have met only on Zoom until now.  I am sitting in my usual seat at the back of the conference room with colleagues – faculty and students who haven’t seen one another except online alongside new onsite participants, and other old and new faces on a large screen from various states and countries. It is only the second hybrid conference IPI has designed, and we are all curious and eager to participate in the integratino of our onsite and online learning community.  It’s a work in progress, an experiment in sharing, sensitivity to the needs of others, and experiencing hybrid as an object of study.  “Everyone hates hybrid,” we’ve heard, but our goal at IPI is to develop expertise in creating an effective hybrid learning environment for communicating across cultures.

April 2024 Hybrid Conference

Now Howard Levine is talking.  “Where are we?” he asks.  This is the central question for the analytic dyad in the unique epistemological universe that is psychoanalysis.  Levine, who is highly conversant with the related elements of theories of Bion, Winnicott, Freud, and Klein, warns us that theories tend to be rather final, exhaustive, exclusive of other ideas, and limiting of growth in the individual psyche and in the field of psychoanalysis.  He allows that models highlight characteristic elements which can be useful for making comparisons between various clinical approaches.  However, he reminds us that assumptions made by theories and models for understanding neuroses  (in which the unconscious is structured by representation of repressed unpleasant experience and desires) cannot be made to apply in the psychoanalytic treatment of all cases.  In widening scope cases, the analyst is responding to fragmented or psychosomatically expressed states of mind that are unrepresented because they are non-ideational.   The task here is to reach a wordless experience in the unstructured unconscious.  Here Levine turns to French psychosomatics and the work of Andre Green.  Heady stuff.  Clearly Levine likes to know the boundaries and break free of them.   His parting shot to us before pausing for discussion — “Are you dislocated enough yet?”

Responding to the word ‘dislocated’, my mind returns to his opening question: “Where are we?” I ask why the sense of place is the central question above all others.  He replies that the whole trend in psychoanalysis has been towards knowing and getting it right.  So, now we need to valorize the space for not knowing, for instability, and for acknowledging that the unstructured unconscious is a force without meaning.  Putting it simply, he says, “There is no there yet.” And that is what we have to be able to resonate with.  As for a more complete exploration of my question, Levine responds: “We will have the whole weekend for that!”

And we will be pondering the questions raised for much longer than that.

Jill Scharff

In Remembrance of Walt H. Ehrhardt

Walt H. Ehrhardt

Dear IPI Community,

On October 27th we lost a valued friend and colleague, Walt Ehrhardt, Ed.D., L.P.C (August 26, 1940–October 27, 2022). Walt was a founding faculty member of IPI National (1996) and a long-serving faculty member in the Couple, Child and Family Certificate Program. He established a minority scholarship fund that came to be known as “Walt’s List,” and he was Dean of Students in the early 2000s. In 2004, he was instrumental in bringing the IPI Weekend Conference—“Object Relations Couple and Family Therapy”—to his native New Orleans and co-chaired it.

Walt served on the Steering Committee of Psychodynamic Psychotherapy Program (PPP) and other IPI committees. He presented, taught, and supervised in the Psychodynamic Psychotherapy Consultation Program and the PPP.  Additionally, he served as the Director of the New Orleans satellite of the International Institute of Object Relations Therapy (IIORT) and maintained a private practice.

Walt had a unique career path—he initially pursued theological studies and later obtained psychodynamic training with children, adolescents, adults, and couples and families. Walt integrated the spiritual with the psychological, often discussing the soul and the self. He worked rigorously and religiously to develop and make use of his kindness and his strength. He was devoted to his community, most noticeably after Hurricane Katrina, when he continued serving traumatized families even though his family experienced the destruction and devastation. IPI will always remember how much he taught us about the impact of personal and environmental trauma.

We share fond reminiscences of Walt. He will remain in our hearts as a fine man, therapist, teacher, and colleague who was warm, empathic, intelligent, giving, kind, hospitable, and nurturing. With these words of remembrance, I offer my warm condolences to all those who are grieving the loss of Walt. He will be greatly missed.



Caroline Sehon
IPI Director

Thoughts on Psychoanalysis: Waiting and Fishing

     Over the last couple of years which have been dominated by the pandemic, we’ve all had to put many things on hold— and wait. Recently, when thinking about waiting, I remembered a short paper I had written in 2014 during my psychoanalytic training at IPI. Three times a year, we were asked to write a short, informal paper about anything related to theory or technique. Writing, as well as listening to my classmates’ papers, was a delightfully fun part of the training.  Becoming a psychoanalyst involves many different kinds of learning — from reading about theory and technique, class discussions, supervision, our own analysis and especially from our analysands. And for me, poetry has always offered clarity and an additional way to understand a concept. Poetic images often stimulate our receptivity, evoke a new kind of awareness, and illuminate the meaning of complex ideas,  helping us to grasp their essence.

     What follows is my 2014 paper,  entitled “Thoughts on Waiting and Fishing”.

     I was recently driving in the car on a Saturday morning, listening to one of my favorite radio shows, “Wait, Wait… Don’t Tell Me!”  The moderator poses questions based on the week’s news, as humorists on the panel, or the call-in guest, compete to provide the correct answer. During that show, my mind drifted, and I found myself wondering about possible topics for this paper. I became curious. Why thoughts about the paper now? Ah……the word “wait”.…it carries weight in my developing psychoanalytic mind.


     Although aiming for negative capability, when that is difficult I can find myself in some version of  “Wait, wait….don’t tell me”, communicating in an indirect way, “Wait, I know the answer”, or “I know where you are going”, or “Wait, don’t tell me, I find that difficult to bear”.


     Being comfortable with waiting brings to mind Winnicott’s description of the early mother/child experience, in which the baby takes time to nurse. The baby sucks, then stops, then starts again when ready, with the sense that the mother is in-sync, because she waits. In this description of waiting, the verb has no object—the mother just waits. There is no sense that the mother is waiting for the baby, which would imply an expectation of how the baby’s feeding should proceed.


     During this period of thinking about analytic waiting and writing this paper, I opened a new book of poems, and in a welcomed coincidental moment there was one that caught my eye—“Fishing with My Father and the Craft of Poetry”, by Ralph Culver.  This new inspiring image of waiting begins:

“Holding poles over the water,

hours of catching nothing or not much,

and throwing back what we did catch.”

     These first lines paint an image of two people with perseverance, and patience, being involved in an activity for the enjoyment of the process, rather than a sense of productivity. They are fully engaged, yet are not in a hurry, and much of the time it doesn’t matter to them if they catch anything.


     A fisherman walks quietly along the water not knowing if there will be anything to catch. Following the stream and his intuition, he looks in every pool, trying not to disturb the fish as he comes near.  Each place he stops is an opportunity, but he can’t leap at it.  He curiously studies their actions and patterns.  He stands out of sight and stays still, in a state of readiness, but not over zealousness, all the while thinking and waiting for the right time.  Based on his scientific skills and his artistic ability to “read the water”, he casts the line and he waits. There may be a nibble of interest, even several, or none.  Fishing for hours, sometimes finding nothing, the fisherman trusts that failures are part of the process.  And, a fisherman is taught that if the fish aren’t biting, then he needs to rethink what he is feeding them. As the poem describes, it can feel at times like nothing is happening, yet faith and patience grow after hours of practice. The poem continues:

“What the hell was that about, anyway?

 And yet today I have this patience

for things that drive some people crazy:

standing in line at the supermarket,

waiting for some fool blowhard to stop gabbing,

searching for a coat button in the snow.”


    The last few lines of the poem point to the conviction and devotion that are common in fishermen, also Winnicott’s nursing mothers and skilled psychoanalysts:

“The finely honed conviction that beneath

this nothing is a deeper, richer nothing.

 Consecrating myself to the silence, and then

to what interrupts the silence.”


     This poem uses the word consecrating, which is usually used in religious writings. To consecrate is to make sacred, and in the broad sense of the word, to regard something or someone with great respect, devotion and dedication.  When practicing psychoanalysis, we respectfully wait in order to give the analysand and ourselves the sacred space to fish around in our unconscious minds and to offer a thought, or not—and trust that something will emerge from our depths.


Michele Reed, M.S.W, is a clinical social worker and psychoanalyst practicing in Waterbury, Vermont. She has been a faculty member at IPI since 2011.  In 2018, she graduated from IPI’s International Institute for Psychoanalytic Training, where she has been a faculty member since 2020.  


In remembrance, Paula Margetts Swaner

December 3, 2021

Paula Swaner


I am sad to inform you that the IPI community lost a friend and esteemed colleague. Dr. Paula Swaner (Nov. 23, 1927–Nov. 30, 2021) was a clinical psychologist, a founding faculty member of IPI National (1997) and Faculty Emeritus beginning 2007, and founder of the IPI Salt Lake City affiliate. Throughout her work at IPI, she maintained a private practice while also engaged in the Salt Lake City psychotherapeutic community and at various community mental health clinics.

Dr. Swaner had a distinguished career as a psychotherapist, educator, and leader. She spearheaded community mental health initiatives, such as the Rocky Mountain Psychological Center (2003) and the “Perspectives on Prejudice” project (2003–2006) in collaboration with the Utah Psychological Association, the Pacifica Graduate Institution, and the IPI. She received numerous awards and honors, including the Heart and Hands Award from Cornerstone Counseling Center (2001), Norman S. Anderson MD Award for Distinguished Service to Mental Health (2002), and Lifetime Achievement Award from the Utah Psychological Association (2008).

Dr. Swaner passionately advocated for environmental protection and preservation. She founded a refuge for wildlife named the Swaner Preserve and EcoCenter. The lovely photo of Dr. Swaner was taken by her daughter, Diana Swaner, as she stood in front of a sculpture created by her son, Leland “Tad” Swaner, in front of the EcoCenter. The EcoCenter is a site for community gathering, and thus an apt image to remember her fondly within our IPI community.

Paula’s generosity was not limited to the preservation of nature and the eco-system, but led her to support colleagues in Salt Lake who aspired to become members and contributors to the community of analytic therapists. She mentored many of them, and contributed largely financially to support the IPI training of the first cohort of Salt Lake City colleagues, had the vision to sponsor IPI’s first use of distance technology so that infant observation and analytic therapy supervision could come to Salt Lake. It is no exaggeration to say that the dynamic psychotherapy community in Salt Lake would not have come into existence without her.

Many of us at IPI share fond reminiscences of Dr. Swaner. She will be remembered as a warm, intelligent, kind, hospitable, and nurturing person who had an unquenchable thirst for knowledge and a fierce determination to accomplish the goals she set for herself and her collaborators. She had a highly developed sense of esthetics and beauty, loved to host gatherings in her beautifully appointed, spacious home, and provided catered gourmet food at virtually every event she sponsored.

Dr. Swaner will remain in our hearts as a treasured psychotherapist and community mental health advocate, as well as a friend, colleague, and IPI presenter. With these words of remembrance, I offer my warm condolences to all those who are grieving the loss of Paula Swaner.


Caroline Sehon
IPI Director


2021 Sigourney Award Recipients

November 23, 2021


Dear IPI Community,

We are pleased to share the news that David E. Scharff, MD, FABP and Jill Savege Scharff, MD, FABP, MRC.Psych. are recipients of the 2021 Sigourney Award.

The Sigourney Award is the highest distinction in the field of psychoanalysis. Founded by Mary Sigourney, the award honors innovative advancement of psychoanalytic thought and practice around the world. Eligibility criteria include initiatives that (1) heighten the visibility of the field of psychoanalysis and its applications to other disciplines; (2) interest young people in studying psychoanalysis; and (3) encompass diversity, equity, and inclusion.

David and Jill Scharff are the first couple to receive the Sigourney Award together in the same year.  The nomination, for which Otto Kernberg and Anne Alvarez wrote supporting letters, earned the Scharffs the award in recognition of their exceptional contributions as pioneers of teleanalysis and training in psychoanalysis, psychotherapy, and couple and family therapy on an international scale. A distinguished panel of independent judges evaluated submissions from five continents. The other two recipients awarded this year are the Erikson Institute for Education, Research, and Advocacy at the Austen Riggs Center and Jorge Claudio Ulnik, MD, PhD from Argentina.  For further information about the Sigourney Award and past preeminent award recipients, you may visit the Sigourney website at

David and Jill Scharff with the bird house given to them on IPI’s 10th anniversary.

Co-founders of the International Psychotherapy Institute (IPI), David and Jill Scharff have been passionate forerunners of distance education since the early 1990s. Prior to the advent of the Internet, the Scharffs and IPI utilized the telephone and later the Intranet (an earlier form of videoconference technology) to link teaching centers in the United States with the United Kingdom, and later with Latin America and beyond. David and Jill Scharff were inspired to deliver quality psychoanalytic teaching and practice and to bring psychoanalysis to nations and geographic areas (beginning with Panama, Long Island and Salt Lake) where psychoanalytic clinicians were absent or rare, and where daily travel would be prohibitively expensive. Their work united psychoanalytic clinicians from Austria, China, Greece, Israel, Latin America, New Zealand, Russia, and South Africa.

The Scharffs were key in legitimizing the field of teleanalysis and teleteaching, methodologies looked upon askance at that time as non-traditional and less effective. As early adopters of teleanalysis and teleteaching, the Scharffs required not only ingenuity, but also courage and tenacity as stalwart supporters of this pioneering approach. Their work in remote learning and practice began three decades before the COVID-19 pandemic, which necessitated such vital techniques to preserve our interconnected lives and work. Inside their professional home of the IPI, David and Jill Scharff still contribute by mentoring and teaching clinicians at all stages of their careers to promote the ongoing development of excellence in psychoanalytic treatment approaches with individuals, couples, families, and communities.

Jill and David Scharff have expressed their intention to donate to IPI their financial award that accompanies the Sigourney prize in acknowledgement of their gratitude to IPI and all the students, faculty and program partners who worked with them to build an international psychoanalytic distance learning community. Specifically, the Scharffs have suggested that IPI use their prize money to create a fund for an IPI annual distinguished guest lecture, an online event to reflect their pioneering devotion to teleanalysis and distance learning on a domestic and international scale. The terms and conditions of this initiative within the IPI will be developed and discussed between the Scharffs and the IPI over the coming weeks. David and Jill’s generous gift exemplifies their kindhearted spirit and tireless devotion to IPI and its promotion of worldwide access to psychoanalysis and the development of future generations of analytic practitioners, educators, and leaders.

Please join us in honoring David and Jill Scharff for receiving the prestigious Sigourney Award.

Warmest wishes,

Caroline Sehon, MD, FABP (IPI Director)

Caroline Sehon, MD
Rich Zeitner, PhD, FABP, ABPP (IPI Board Chairman)

Your Child Is Struggling. Could Your Marriage Be to Blame?

David Scharff, MD

The health of your partnership plays a major role in your child’s mental health.


  • Maintaining marital and personal satisfaction creates a huge benefit for the mental health of families and their children.
  • Research shows a link between the parents’ relationship and their child’s social and academic outcome.
  • Therapists should consider the parental dynamic when addressing mental health issues in children.

Well-documented research cites trauma, socioeconomic status, education, peer effects, parental bonding, nutrition, and sleep habits as clear contributors to a child’s overall health outcomes. But one unique area of research — and one not often addressed — has shown that the role of the parental couple’s relationship also has a hugely significant effect on the health of their children.

Study: The couple relationship and children’s health

Both born in Toronto, Drs. Phil and Carolyn Cowan are both professors emeritus at UC Berkeley. When they began their work in the 1970s, there was no research on the role of the couple relationship on the outcomes for children’s health or overall adjustment. And many child therapists did not even allocate regular time to seeing parents at all. There was a fair bit of research on parenting — as well as John Bowlby’s pioneering work on attachment theory — but nothing that looked at the couple’s dynamic, in and of itself, as a cause for a child’s emotional health.

The Cowans’ research considered this dynamic. They noted that marital satisfaction and happiness decline after having children, and surmised that this decline adversely affects their children’s wellbeing. (The decline in marital and personal happiness in parenthood is well documented. Many couples never regain their pre-child levels of satisfaction with their lives, or perhaps not until the children leave home, and by then divorce has often intervened.)

The Cowans devised an intervention: a 16-week peer couples’ group, facilitated by clinically trained co-leaders. Two similar group interventions were designed. Each provided a similar curriculum, but with a different focus. After the unstructured opening segment of each week, the curriculum then focused on either (1) improving the couple’s wellbeing as a couple or (2) improving their parenting skills.


The most impressive gains resulted in the first group: Couples maintained (though did not improve) their previous level of satisfaction with their marriage. Other significant improvements did occur in the second group: fathers’ parental participation rates, children’s academic performance, and the parental relationship as it related specifically to their shared parenting.

To be more specific, both groups showed improvement, but the group that focused on the relationship between the parents talking about their own issues showed superior results, especially in supporting their children’s social and academic achievement. While the parenting-focused group did help with parenting, the relationship-focused groups did both that and also affected the quality of the relationship between the parents. (A surprising bonus came when the researchers discovered an unintended consequence: Overall, the families also increased their income.)


Over subsequent years, the Cowans have validated that initial finding: Maintaining marital and personal satisfaction and reducing couple conflict creates a huge benefit for the mental health of families and their children. The emotional challenges of having children are well known; we all know that having young or adolescent children in our lives — while very much worth the pain — is indeed often a pain! Never before has a research project looked at the toll this change can take on parents’ mental health and marital health, and then intervened with treatment intended to reverse the damage this inflicts on their children.

The intervention trials originally were conducted with working- and middle-class couples, but in the last two decades, in collaboration with Marsha Kline Pruett and Kyle Pruett, they have shown that the same curriculum and format leads to positive results for parents and children in more than 1,000 ethnically diverse low-income families.

Carolyn and Phil Cowan. Source: Photo supplied by authors.
Carolyn and Phil Cowan.
Source: Photo supplied by authors.

The Cowans’ work has been replicated in other countries, including Canada, Malta, Poland, and England. In England in particular, the government has funded a large project through Tavistock Relationships (TR), with the collaboration of the Cowans. So far, the British program is the only one that actually showed an increase in marital satisfaction! Phil Cowan guesses that is due to the advanced skill of the group leaders at TR.

The Cowans’ discoveries and research deserve to be more widely known as the groundbreaking work that it is. I recommend their work and that of their collaborators as basic reading for family, couple, and child therapists everywhere.


Cowan, C. (1970, August 1). Transitions to parenthood: His, hers, and theirs – Carolyn Pape Cowan, Philip A. Cowan, Gertrude Heming, Ellen Garrett, William S. Coysh, Harriet Curtis-Boles, Abner J. Boles, 1985. SAGE Journals. Retrieved October 25, 2021.

Cowan, C. P., & Cowan, P. A. (2000). When partners become parents: The Big Life Change for couples. Lawrence Erlbaum Associates.

Cowan, P. (2019, March 1). Fathers’ and mothers’ attachment styles, couple conflict, parenting quality, and children’s behavior problems: An intervention test of mediation. Taylor & Francis. Retrieved October 25, 2021, from

Lawrence, E., Rothman, A. D., Cobb, R. J., Rothman, M. T., & Bradbury, T. N. (2008, February). Marital satisfaction across the transition to parenthood. Journal of family psychology : JFP : journal of the Division of Family Psychology of the American Psychological Association (Division 43). Retrieved October 25, 2021, from

McGreevey, S. (2018, April 16). Study flags later risks for sleep-deprived kids. Harvard Gazette. Retrieved October 25, 2021, from….

Pauly, C., Cowan, P., and Cowan, C. (2017). Parents as partners: A U.K. trial of a U.S. couples … (n.d.). Retrieved October 25, 2021, from….

Parker, G., Tupling, H., & Brown, L. B. (2011, July 14). A parental bonding instrument. British Psychological Society. Retrieved October 25, 2021, from….

Putnam, F. W. (2009, July 14). The impact of trauma on child development. Wiley Online Library. Retrieved October 25, 2021, from….

Robert H. Bradley and Robert F. CorwynCenter for Applied Studies in Education. (n.d.). Socioeconomic status and child development. Annual Reviews. Retrieved October 25, 2021, from….


David E. Scharff, MD, is the Co-Founder and Former Director, the International Psychotherapy Institute, and a Supervising Analyst in The International Institute for Psychoanalytic Training, IPI’s analytic program. He is Co-Chair of APsaA’s COVID-19 Advisory Committee and a member of APsaA’s Distance Analysis Study Group. He also directs training programs in China and Russia.

Six Hard-Won Lessons: Teaching Psychoanalysis Online

David Scharff, MD

Scharff, D. E. (2021). Six Hard-Won Lessons: Teaching Psychoanalysis Online. The American Psychoanalyst, 55(3), 29–30.

The International Psychotherapy Institute (IPI) and its psychoanalytic training program, the International Institute for Psychoanalytic Training (IIPT), were founded as distance learning programs. So, the question of how to conduct effective teaching across geographical distance has always been front and center in its conceptualization of programs and in teaching. I wrote an article for the Journal of the American Psychoanalytic Association about this several years ago (Scharff, 2015) to share what we had learned about effective teaching to students who were not geographically together. But events in the intervening years have overtaken what could be said then, so I am most appreciative to Alan Sugarman for inviting me to update our learning in light of the suddenness with which all institutes and psychotherapy training programs have had to move online, most with little or no preparation.

The first thing to say is that good online teaching is centered in good teaching. If teaching technique does not work well in the in-person classroom, it will not work online either. For instance, a teacher reading from a paper or from lecture notes with her head down for an extended period of time is ineffective in a classroom, and even worse online. Now that we all have experience, it will perhaps come as no surprise that promoting discussion using Zoom – which is the best platform (to my mind) and most common one – can be pretty much as effective as doing so in an in-room class.

Participants at a Master Speaker training at IPI

IPI has used distance teaching at many levels of scale. In the beginning in 1995, “distance education” meant that all our students had to travel several times a year to join us in Washington, DC. This was expensive for out-of-town students; nonetheless many found it worthwhile because they came from places with no analysts or even analytic psychotherapists from whom to learn. Others came because they wanted access to our particular theoretical orientation in object relations psychoanalysis. Recall that in the 19th and early 20th centuries, Americans wanting to learn psychoanalysis usually went to Vienna or Berlin, and later London. That was only possible because trans-Atlantic travel and travel by rail had improved over the previous decades, making it finally practical to travel long distances. Although the telephone was invented around the turn of the 20th century, calls were too expensive to be useful for treatment, education, or supervision.

Twenty-five years ago, the phone was inexpensive and so we used it for individual supervision, small group “conference call” seminars, and group supervision. And it worked pretty well. We might have wished we could be in a room together, but it was nevertheless satisfying to be sharing ideas and clinical experiences on the phone. Then, in the late 1990s, came the internet, and a subsidiary technology called the “intranet” offering the possibility to link sites for real-time audiovisual communication. It was relatively expensive but could link up to four sites at a price IPI decided to afford. So, we linked Washington, DC with London, Salt Lake City, and Long Island. In that way we could import teaching from London or New York to three American sites where we could gather students. As far as I know, we were the first in our field to do this. One of our board members cautioned me that there was considerable wisdom in being the second group to try something new in order to let someone else work out the bugs; but we forged ahead. Despite the frequent technical glitches, we found that a great deal could be learned working together as a group across the four sites. We partnered with two divisions of the Tavistock, especially the Clinic and the Institute of Marital Studies (now Tavistock Relationships), over several years, sponsoring joint programs with some students on both sides of the Atlantic. And we could use presenters from the New York area, or invited guests, to present at one of the other sites who could then teach to all four via the intranet connection.

IPI telelink training early 2000’s

And then the technology mushroomed. Suddenly we were able to offer large group seminars to individuals sitting at their own computers in the comfort of their offices or homes. And we could invite guest teachers from anywhere in the world. At first, the available technology was pretty clunky and often subject to disconnection. But, as we all know, with the advent of current platforms (Zoom,, FaceTime, Google Groups) it has “zoomed along.”

Here is what we do now at IPI:

  • Large group seminars with all participants able to join in and speak during discussion periods. We do not do webinars because they constitute one-way delivery and therefore, over time, we decided it is the least effective teaching medium. We feel that people learn best when there is discussion in a group of any size. So, we have groups of up to 150 or so. (Our Zoom contracts allow 300 participants without having to buy a more expensive license, although larger group sizes are available.) We ask presenters in our seminar series to present for approximately ½ the time of a seminar. For instance, we ask for a one-hour presentation if the seminar is for two hours, with several pauses throughout the presentation for discussion. That way the audience feels listened to and the presenter receives feedback throughout the presentation. Even though only a minority of participants speak in a large group, the possibility of speaking changes the receptiveness of the entire group. Participants also use the chat function to comment or ask questions. We strongly believe in interactive learning, no matter the size of the audience.
  • We use the large group meeting feature for institutional events: Faculty meetings, meetings of our entire center, and Town Halls that draw participants from all over the world (China, Australia, South America, Europe) to discuss issues of mutual concern – racial issues, issues of culture and ethics, COVID and its effects.
  • Small group seminars the size of an analytic or psychotherapy class, work well on Zoom. Teachers and students can all see and hear each other well. It is just as possible for a teacher to elicit group discussion on Zoom as it is when students are in-room. We encourage group discussion in these settings and discourage teachers from simply lecturing without time for group participation. That makes real learning of the kind afforded by small seminars entirely possible on zoom.
  • COVID travel restrictions have prompted us to offer weekend conferences online. Candidates, students, and other participants work with a distinguished guest and IPI faculty in large and small group settings over three days of intensive learning. Enrollment has steadily increased during the pandemic, in part because these conferences do not require the difficulty, added time and the expense of travel.
  • What does not work as well is a so-called “hybrid” classroom with some students in the room and some online. In a preliminary survey done by the APsaA’s Distance Analysis Study Group, a number of candidates complained about seminars with this hybrid mixture. They reported that this approach disadvantaged the distance candidates. Their preference was for “all on-line” or “all in-room”.
  • Supervision is especially convenient and effective online. In my own experience, there is no difference in effectiveness between in-room and on-line supervision and consultation. This applies equally to individual, paired and group supervision. I can see my supervisee(s) because I ask them to have their cameras on – unless a broadband weakness requires a disabled camera for improved transmission. Some supervision pairs prefer the telephone; that, too, is effective. Allowing the supervising pair to choose is just as important as it is when doing clinical analysis or psychotherapy.
  • The largest downside of distance-mediated education, what we all miss most, is the informal time – meeting in the hallway over coffee or a drink after class. It is possible to make some accommodation for this loss by scheduling a group chat for a class or faculty, but we look forward to being physically together as we creep back to normality. Reinstating the social aspect will be easier because we have stayed in touch online in the meanwhile.
David Scharff facilitating distance learning from his computer

Our hard learned lessons for teaching by internet:

  • Always keep in mind the group dynamics.
  • Monitor the group: Who is speaking? Is the group participating or only listening passively? Are one or more students hiding out without participating, perhaps helped by turning their camera off?
  • Involve the group members. Do you want candidates or students to prepare to present material, for instance from the readings? Or to summarize a topic from their own study? Or to address questions supplied in advance in order to focus their reading?
  • Technical glitches will happen! Have you prepared a fallback plan to switch to another platform — FaceTime, Google Groups or cell phone? Be sure to have everyone’s email and phone numbers so you can call or text easily to facilitate connection for a student or faculty member.
  • Review with the students how the teaching is going periodically. There should be both formal review by the course or program organizer, and by a given teacher with the group. This is especially important online because there is some diminution in non-verbal cues. But we can make up for that by reviewing the teaching and learning in tactful but overt ways that should be initiated by the teacher. Otherwise, dissatisfaction can accumulate while being expressed only tacitly through resistance like being overly complaint to the teacher or organizers while learning little.
  • Finally: Learn to enjoy yourself via the face-to-face connection with students on Zoom. You will have saved commuting time, and have the comfort of your own office, just as they do. While I hear many complaints about “Zoom fatigue”, it does not have to be exhausting! With experience, you can learn to relax during teaching just as you need to relax while conducting therapy. Teaching and supervising should be more than work. They should include the pleasure of helping less experienced colleagues grow. We have had an incredible opportunity to continue to teach and learn in the time of a pandemic. And for sure, this worldwide misadventure will also lead to an expansion of what is possible in the teaching and spread of psychoanalysis after the pandemic recedes.



Scharff, D. E. (2015) Psychoanalytic Teaching by Video Link and Telephone. Journal of the American Psychoanalytic Association, 63:3 pp. 443-468.


David E. Scharff, MD, is the Co-Founder and Former Director, the International Psychotherapy Institute, and a Supervising Analyst in The International Institute for Psychoanalytic Training, IPI’s analytic program. He is Co-Chair of APsaA’s COVID-19 Advisory Committee and a member of APsaA’s Distance Analysis Study Group. He also directs training programs in China and Russia.

Watching Afghanistan from Iran

August 16, 2021


I don’t know if you hear the news about Afghanistan or not. The government has fallen and their president fled. The whole country is now under the rule of Taliban and they are real hard liners. I have a few friends in Afghanistan who are authors, reporters and translators. I met two of them here while they were studying Persian literature or English literature in the University of Tehran. They have horrible, horrible news to tell. Taliban has closed down universities, fired female professors (they strongly oppose female education) kidnapped girls of over 12 for sexual slavery (they sell them to their soldiers as brides) and they are looking for journalists and particularly female journalists. (I don’t really know what is the matter with them about women?!) These scholar friends of mine have fled from different places to Kabul seeking help. Many went to Iran’s embassy to receive a visa but the embassy refuses them and now, I don’t really think they might be able to leave Afghanistan as Taliban seizes control. The civilian airports are closed down too, and everyone has to wait.

When I was a junior student, I used to work with an NGO here in Tehran who organized humanitarian aids to the poor living in the slums on the outskirts of Tehran. Many of them were children of Afghan immigrants. I used to teach them Persian literature (they are Persian speakers too). Others would teach them math or science or whatever they could. We got in contact yesterday, and they asked me if I can provide some psychological help for women and children who have made it to Iran, and I certainly agreed. My friends in Kabul tell me how they have hidden their sisters and daughters in the mountains, as the Taliban is trying to identify the families with daughters over 12. It is just horrible. We are also trying to see how we can request visas at least for our friends. I also remember a sad story.  When I was in high school, I used to burn the midnight oil in a nearby library. There was an old Afghan man there who was the janitor and cleaned the reading halls and tables there. When I got to know him, I found that he was a poet and an author and editor in his home town in Afghanistan, and now he had become a simple worker in Tehran. Thankfully, the manager of that library gave him a nightly job: he got to catalogue the new books that came to the library. His story was quite sad.

I would be happy to think that the voice of my friends in Afghanistan might be heard through this blog. Thankfully, I am able to do something to facilitate their visa process. I was able to find a man to whom I used to teach English when I was a freshman. He ended up working in the ministry of foreign affairs, and he promised to intervene in the interest of my friends in Kabul. It is awful to tell you that one of my friends had to send his widowed sister and his niece to a hideout in the mountains to keep them safe from the Taliban forces so as to buy more time to see what he could do. I am sure the Mullahs in Tehran have found allies in the Taliban in Afghanistan and things will get way uglier both for us in Iran and for the Afghan people there. Earlier today, our national television broadcast celebrations of Taliban take-over and tried to show this as an embodiment of the will of people, as if the Afghan people have risen against their corrupt regime and have freely chosen the Taliban, but my friends in Afghanistan have a totally different story. The Taliban will be the second Islamic republic of the region but much more brutal. The Taliban have an office in the religious city of Qom in Iran and today, demonstrators who were opposing them in the city of Qom were arrested by the police. Months before all this, the leaders of the Taliban had meetings with authorities in Tehran. So far we are safe in Tehran. Thankfully, I have found a way to help my few friends in Afghanistan, and I am counting the days to see if they can receive a visa and leave for Iran. One of them in particular is a female journalist who has been active in criticizing the Taliban. I never understood the Islamists’ misogyny. It is just horrible. My only fear now is the coalition of Taliban and Iran. That day, I think all of us will be in great danger if we want to stay the people we are.


As you can tell, we are all anxiously watching the turn of events there.


Mahyar Alinaghi

IPI Combined Child Program student


For those who are interested in a free community discussion, you can join our Town Hall (FREE). Simply click the zoom link below to join us on Sunday at noon US eastern time.

This Sunday, August 22, 2021 – Special Town Hall in response to the Afghanistan humanitarian disaster (12pm-1pm US ET)-


The Two Kinds of COVID Couples

The pandemic can draw couples closer—or push them apart. Here’s why.

I’m a psychiatrist and psychoanalyst specializing in couples and family therapy. Like many people across the world, many of the couples I work with have been struggling through the hardest year of their lives. People who maintained their marriages by spending very little time together—usually with one partner working outside the house—were now, for better or worse, unable to take time apart.

The pandemic has had an amplifying effect on partnership dynamics: some couples pull closer, while others push away from each other. By the numbers: In China, 18 percent said their relationships were slightly worse at the beginning of the pandemic, and a full 29 percent of respondents reported their intentions to divorce after the pandemic (Tian 2020c). The same phenomenon surfaced worldwide.

As conflict increased when couples were confined together, some marriages went from contentious to unbearable, leading to an urgent need to divorce. In Wuhan, China, the initial site of the pandemic, a spike in divorce rates was one immediate effect. Early reports documented increases in marital and family distress and a surge in family violence. This increase in family violence was so critical that it has been described as a “double pandemic” (Bettinger-Lopez and Bro 2020) as well as a “new crisis” (Taub 2020).

Negative outcomes during COVID, particularly domestic violence, have also been a function of social structural factors. This included poverty, unemployment, food or housing insecurity as well as social isolation, issues of racial tension, and ecological features (Flowers 2000; Gelles and Maynard 1987; Utech 1994). Domestic violence is more common in families of lower education and incomes, but it certainly happens in all social and educational groups. As the pandemic exacerbated many of these issues, an uptick in domestic violence was, tragically, predictable.

But not all couples find themselves teetering on the edge of divorce; according to the same poll mentioned above (Tian 2020c), 41 percent of partnered couples have seen improvements in their relationships during the pandemic. This begs the question: why have some couples pulled closer during the pandemic, while other couples drifted apart?

In analyzing my own clinical experience, as well as the available data, several trends have emerged. Here are some observations:

Negative-Outcome Families

CASE STUDY 1: The Smiths moved in the midst of the pandemic. Both parents worked high-stress jobs and, even before the pandemic, had limited time for family bonding. Their adolescent daughter, now faced with online schooling in her new school, never could construct a social group, and her stress ricocheted around the family, stressing her parents and driving a wedge in their marriage. The pandemic’s isolation was the cause for the husband’s secret affair that now came to light, resulting in intolerable marital tension when he was unable to move out because of quarantine.

In this example, we see a textbook case of stress, poor communication, disconnection, and resentment that brought the couple to a breaking point. (This is not uncommon during times of public health crises; war, famine, and disease outbreaks set off depression, anger, and anxiety caused by isolation and loneliness.) During historically trying times, everyday stressors may become too much to bear. Moreover, pre-existing vulnerabilities or personality traits may be exacerbated, including the expression of hostility, dominance, stubbornness, or rigidity (Prime, 2020). These factors create a feedback loop of stress, resentment, and withdrawal.

Additionally, certain family dynamics predispose us to the risk of marital uncertainty. For example, being in a blended family (a family with children who are shared between divorced and remarried parents) is one stressor that has been shown to increase the likelihood of marital strife during the pandemic. Another component is the presence of young adults preparing to leave home for school or work. As many young people are now having to change plans, often amidst a family dynamic that is already primed for stress and conflict, this circumstance begets a host of possible challenges.

To summarize, negative-outcome couples evince some of the following characteristics:

  • Poor communication
  • Mutual blaming
  • Ongoing social isolation, particularly with respect to loss of outside emotional support systems
  • Loss of jobs or income (Campbell 2020)
  • High-stress states before the pandemic
  • Divorced or blended families
  • Children on the cusp of leaving home

Positive-Outcome Families

CASE STUDY 2: The Greens used the quarantine to work on longstanding challenges in their marriage. They shared a renewed focus on their children’s schooling, rebalanced their household division of labor, and managed the emotional burden of the pandemic as partners. They also used their time together to work on their sex life through sex therapy, which had needed more focus for years; they were, fortunately, able to keep their children in daycare so they could carve out “together time” at lunch, rather than only thinking about sex when they had finally put work and their children to bed.

Why is the Greens’ pandemic story so different from the Smith’s? They consciously chose to structure their lives around the needs of the other partner. They worked consistently, and collaboratively, to improve communication and conflict resolution, practicing “I feel” statements in place of accusations or stonewalling. They set goals—and boundaries—around how much of their pandemic lives would be about their children’s wellbeing. And, they continued to see a therapist throughout the pandemic, proactively improving their communication skills and their sexual functioning.

Positive-outcome couples demonstrate the following traits:

  • Constructive communication
  • Enhanced mutual empathy
  • Quick and consistent conflict resolution
  • Multifactorial problem-solving skills
  • Shared emotional labor (Neppl et al., 2016)
  • Willingness to seek help, including psychotherapy (and/or sex therapy) as a preventative measure

The pandemic is “perhaps the most widespread social experiment of all time” (Lebow, 2020). While these lists may be helpfully kept in mind, not all couples have the same capacity for change or growth, particularly in high-stress situations.

As therapists, we, too, have been grappling with the stressors of the pandemic, so we have been sharing that with our patients and couples on an unprecedented scale. We can use that fact to our advantage as we identify with what our clients are going through. As we learn about their anxiety and stress, illness and loss, unemployment and financial uncertainty, it may be just a bit easier to remember that partnerships—even in the best of times—require both partners to enlarge their capacity for patience, empathy, commitment, and willingness to support each other. Many of these couples can profit from the skilled and timely attention of a psychotherapist, who, as they will all know, are themselves also living with the stresses of the pandemic.


Bettinger-Lopez, C., & Bro, A. (2020). A Double Pandemic: Domestic Violence in the Age of COVID-19. Retrieved from Accessed June 8, 2020.

Campbell, A. M. (2020). An increasing risk of family violence during the Covid-19 pandemic: Strengthening community collaborations to save lives. Forensic Sci Int: Reports, 2.

Flowers, R. B. (2000). Domestic crimes, family violence and child abuse: A study of contemporary American society. Jefferson: McFarland & Company.

Gelles, R. J., & Maynard, P. E. (1987). A structural family systems approach to intervention in cases of family violence. Family Relations, 36, 270–275.

Lebow J. L. (2020). Family in the Age of COVID-19. Family process, 59(2), 309–312.

Neppl, T. K., Senia, J. M., & Donnellan, M. B. (2016). Effects of economic hardship: Testing the family stress model over time. Journal of Family Psychology, 30(1), 12–21.

Taub, A. (2020). A new COVID-19 crisis: Domestic abuse rises worldwide. New York Times, 6.

Utech, M. R. (1994). Violence, abuse, and neglect: The American home. Lanham: Rowman & Littlefield.

Zhang, H. The Influence of the Ongoing COVID-19 Pandemic on Family Violence in China. J Fam Viol (2020).

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.

Returning to In-Person Treatment During COVID-19 – If, When, and How

Original August 4, 2020

Revised January 16, March 11, April 29, 2021


Dear Colleagues,


If you’re thinking about returning to in-person work, or have already done so, we hope you will find these ideas helpful. This is a long document, so here are the key areas:


  • Maintaining uncertainty
  • Different practices & risk tolerances lead to different decisions
  • Not shaming those who work differently
  • Beliefs about online vs. in-person work influence our risk assessment
  • Wishes and fears about resuming in-person work
  • Child work
  • Transference
  • The new normal may require being more directive
  • A hybrid model for working in-person, online, and the phone.


Dan Prezant, Acting Co-Chair

David Scharff, Co-Chair

APsaA Covid-19 Advisory Team



Opening Day?


Returning to In-Person Treatment During COVID-19 – If, When, and How



Given that some analysts and therapists have returned to in-person work with some (or all) of their patients, many are considering doing so, and some have decided not to, the APsaA COVID-19 Advisory Team and the APsaA Reopening Task Force are sharing thoughts on in-person work. Our goals are to encourage thoughtful analytic approaches and not shame anyone for how they work.


Changing from working in-person to working via video or phone was difficult. Having to do it overnight, with little or no preparation, made it even harder. However, it was a crisis, so we rose to the challenge and adapted. Most of us defended against the harsh reality of COVID-19 by thinking it wouldn’t last long. Once the terrifying sprint became a depressing marathon, the question became: When can we get back to normal? Now that we’re getting vaccinated, the question is: Are we done? Only you can answer that question for your practice.


Tension exists between those who recommend not making any significant changes in COVID precautions post vaccination vs. those who recommend that post vaccination life can almost go back to normal. Some feel that the push to relax precautions is driven by a desire to motivate vaccination acceptance. After all, why go through the difficulties of finding and getting vaccines if they don’t change what we can do? Some of us, who typically follow trusted sources, find themselves questioning the CDC or NYT because of past mistakes, miscommunications, contradictory advice, economic and political influences, and/or our resistance to change.


We are NOT taking a position on whether you should work in-person.  Nor are we making a statement about how you should work in-person if you choose to do so. Our ideas are not best practices or mandatory guidelines for everyone to thoughtlessly follow.


We ARE taking a position that maintaining an attitude of uncertainty is good. Being certain that you can never return to the office or that being fully vaccinated is all you need may be different ways of avoiding the same complicated problems and feelings. We recommend remaining curious and tolerant of not knowing the “right” thing to do. Part of living with uncertainty is letting yourself change how you work as the situation and/or your feelings change.


Shaming those who go back to in-person work or those who remain online may be ways of creating certainty and/or enemies. However, hubris sacrifices the analytic principle of recognizing what we don’t know while we seek to know. Respecting those who work differently during COVID may help us question our decisions and be open to change.


Every practice is unique. It is not possible to offer a one size fits all solution.  So much is in flux. How you work depends on your risk tolerance, how necessary you think in-person work is, how effective you think online/phone work is, how directive you feel comfortable being with your patients, if you work with kids, very disturbed patients, inpatients, do testing, the underlying health risks of your patients and their families, the underlying health risks of you and your family, if you have staff in your office, if you share your office, if you’re in a suite or single office, the physical nature of your office, the local climate if you plan on leaving your windows open, whether your patients will typically be waiting for their session while sitting in their car or standing on the street, the local viral incidence, local vaccination rates, local prevalence of anti-maskers and anti-vaxxers, how concerned you are about COVID variants, long haul effects, and the strength of post vaccination immunity, and insurance reimbursements for tele-treatments.


Many of us struggle with wishes to and fears of returning to a pre COVID-19 world.  Part of us wants to get back to normal. We have anniversary reactions and battle fatigue over cumulative trauma. We want to stop living in fear and in isolation. Part of us fears disease risks (variants, length and strength of post vaccination immunity, breakthrough infections, long haul effects), our own phobic feelings, the now foreign feeling of being in our office with patients, intense feelings that can come with a shift to in-person meetings, and discomfort showing our heavier bodies (did you gain 19 lbs. during COVID-19?).


Some of us find working from home with partners, kids, and pets around surprisingly comfortable. Some find it quite uncomfortable. Some enjoy the extra family time and lack of commuting. Others long for the separation between their work and family lives. For some being home and taking care of kids, chores, errands, exercise (that used to have to wait until after hours) is a benefit and for some it’s an onerous demand. Some have given up their offices for financial, health, or other reasons.


Many therapists and patients prefer in-person work and believe it is the most effective.  Those who feel strongly that online/phone work is not effective will understandably feel a greater need to return to the office.  Many analysts and patients have found that online/phone work is different, at times better, at times worse, but still quite effective.  Understandably, they will feel less of a need to return to the office. These beliefs likely influence your assessment of the risks.


Seeing patients in-person or via telehealth is an important decision with powerful ramifications on the physical and psychological health of our patients, their families, their coworkers, and ourselves. Insurance reimbursement is important to many of us and to our patients, but it shouldn’t be part of this equation. Thus, state and federal rules and regulations should permanently require equal insurance reimbursement for telehealth.  Unfortunately, this is not yet the case.


Most of us who reopen will do so in stages, starting with patients who we trust are vaccinated and safe.  It’s unlikely there will be one opening day in which everyone comes in. This may help us, and our patients adjust to in-person work. Seeing patients in-person may be a new normal, but it won’t be the same as going back to the old normal. Please consider:


  1. Psychological Factors:


  1. To be an effectivetherapist you need to be comfortablewith how you work, whether in telehealth or in-person. If you’re too anxious to think, then you can’t help your patients. If in-person work replaces your free-floating attention to the patient with anxiety, anger, or guilt about spreading and/or catching COVID-19 it may be best to wait.


  1. Creating and maintaining a safespacewhere the patient feels as free as possible to express their innermost thoughts, feelings, wishes, fears, and fantasies is fundamental to our work. Working in-person may inhibit some patients from being open about their vaccination status, risky behavior, COVID type symptoms, and/or wishes to hurt us. We may fear that patients will consciously or unconsciously not tell us information that might affect our safety. Alternately, working online may inhibit some patients from being open about their fears that we are sick, don’t want to see them, and/or their wishes to hurt us.


  1. In-person work during COVID may require us to be muchmoredirective. It’s true, we’re directive online (during COVID) and in-person (pre-COVID) about where we meet, appointments, bills, etc. However, in-person work during COVID may entail an unusual level of directiveness. Depending on what you think is necessary for in-person safety, you may need to tell patients they have to be vaccinated, show you their vaccination cards, wait outside and not use your waiting room, not have anyone wait for them in your waiting room, not use your bathroom, take their temperature, wear masks in the building, waiting room, and/or in the office, not come to the office when they have COVID symptoms, travel, or engage in risky behavior, and/or participate in contact tracing in which you might have to give their contact info to the local health department.


  1. Being so directive impactsthe expression and exploration of the transferenceand countertransference. It may put us in the role of a parent, doctor, or teacher instructing and judging the patient. This tends to limit the transference and its exploration.


  1. Patient’s fears and/or wishes of hurting and/or being hurt by us, our family, and/or our other patients can best be explored when they are fantasiesinstead of realities. In the COVID-19 world, telehealth may prevent these fantasies from becoming realities and thus help us work on the transference.  In-person work may create so much fear about reality that it becomes too difficult to explore the fantasy. Alternately, being online can limit the transference and countertransference.  If there’s no possibility of actualizing wishes to kiss or kick, so to speak, it can deaden the therapy.


  1. Reopening the office in stages may help us be safe.  However, it may also amplify siblingtransferencesabout which patients are your favorites.


  1. Kidsmay be the most in need of in-person work.  Some of us feel it’s not possible to work online with very young kids or that if you do so you have to change the way you work with them (for example, involving the parents more directly in the session). However, kids are not vaccinated and likely won’t be eligible for quite some time.  Kids also tend to be very physical in sessions which greatly increases the analyst’s or therapist’s exposure.  Kids are brought to sessions.  They often need their parent or nanny to stay in the waiting room in case they run out, need to leave early, or need help in the bathroom.  Kids get sick frequently and come to sessions with symptoms that are similar to COVID symptoms. Young kids have trouble blowing their nose, wiping, and washing which also increases our exposure.


  1. Many of us have concerns about our practices which will likely affect our assessment of the risks and our comfort working in-person or online. We may fearlosingcurrent patientswho want, demand, or need to be seen in-person. We may have concerns about getting new patients if we can’t see them in-person.


  1. Many of us have concerns about insurance not reimbursing, reducing the reimbursement, or requiring us to use their platform for telehealth.


  1. Some feel it’s not possible to do psychological testingonline.


  1. Those who practice in areas or with patients who don’tbelievein vaccinesmasks, and/orphysical distancing face added risks working in-person. They may also find it more challenging to remain neutral or not get into arguments about reality.


  1. If you’re working in-person with vaccinated patients, is it discriminatoryto not meet in-person with patients who are too young to be vaccinated or say they can’t get vaccinated because of medical or religious reasons? Given that we have to feel safe to be therapeutic, how do we work with someone who’s not vaccinated?


  1. In-person work may model denialand risk-taking behavior for our patients. Online work may model phobic and risk-averse behavior. Whichever way you work, it’s important to explore what it means to the patient so that we don’t promote a defensive not knowing.


  1. Depending on what you think is necessary for in-person safety is it more or less therapeuticto meet in-person with safety conditions (for example, checking vaccination cards, wearing masks, closing your waiting room) or to meet online without those conditions. Each approach will likely affect the work in different ways.


  1.  Avoidthe temptation of giving a patientwho you think isn’t safe (unvaccinated, symptomatic, risky behavior) the choice of how they want to meet. This may appear to be empowering, but it may also be a way of denying our ultimate responsibility for the safety of the patient, their family, our other patients, and ourselves. Giving this type of patient a choice may be a way of protecting us from our guilt, but it shifts the guilt onto the patient. We shouldn’t ask patients to make decisions for the safety of our other patients of for our safety and that of our family.  It should be your decision, not the patient’s. Again, this requires us being directive.


  1. Going back to in-person work when there is a chance of returning to telehealthwork because someone gets COVID and/or there’s an increased positivity rate in your community decreases the stability inherent in the structure of regular appointments. Alternately, not going back to in-person work because of these possibilities will have meaning for your patients.


  1. Consider that the patients who may needin-person work the most because they easily feel abandoned and/or tend to need to see us as a check against their destabilizing fantasies about our hostility toward them are also the patients who may be most negatively impactedby our safety procedures (i.e., requiring vaccines, masks, symptom checks).


  1. If you reopen, how will you understand and what will you do with patientswho don’twantto work in-person or only want to come to your office some of the time? How do we stay neutral and avoid making value-based decisions about what’s an “acceptable” reason (e.g., I feel sick, I might have COVID) vs an “unacceptable” reason (e.g., I’m calling because I just remembered our appointment)? Some of us may be directive and give patients rules to follow. Some may try to interpret the patient not working in-person as resistance or avoidance of the best possible treatment.  Some may see it or work with it differently.


Many of us did not work on the phone or online with our patients pre-COVID. We could simply say: I don’t work that way. Most of us can no longer say that. Some of us might choose to say: now that we can meet in-person, I no longer work that way.


Should we move to a hybrid model where patients can choose in-person, online, or the phone? If you use a hybrid model, will you require patients to choose one or the other? If your patients choose to meet in-person, what will you do if one day they call or go online instead or vice a versa? Will you ask them to give you advance notice? Will your online or phone patients surprise you by showing up in-person or vice a versa? If you see patients back-to-back and use a hybrid model, how will you quickly navigate from working in-person to phone to online? How will you know whether you should go to the waiting room, turn your ringer on or off, or log into or out of your online platform? Will you be waiting for your patient to show up in-person and not notice that they are calling you or waiting for you online or vice a versa?



  1.  Local Prevalence of COVID-19 and Vaccination Rates:


Consider the percentage of people in your local area who are testing positive and the percentage who are fully vaccinated. You can go online and get current incidence rates for your county here. Keep in mind that patients and/or their families may live or work in neighboring counties and/or travel. If your practice is in a tourist area, people may be exposed to folks from all over. If the positivity rate for your local area is less than 5% it might be safer to see patients in-person. Ideally, you may want the local incidence to be 1-3% for in-person work. These numbers can change quickly and if they go above 5% you may want to stop doing in-person work. You may want to discuss with your patients that depending on the numbers you may have to go back to only doing video and phone treatments.



III.  Office Setting:


The type of office you work in may influence your comfort doing in-person work as well as your ability to accomplish the actions discussed in the next section. A freestanding private office with open windows, lots of ventilation, and its own entrance and bathroom(s) will be safer for your patients and you than an office in your home, or an office in a residential or office building which requires sharing entrances, elevators, and bathrooms. If you share your office with other therapists, work in a suite, or have office staff you may feel obliged to consider their comfort with in-person work. If you choose to close your waiting room, you may want to consider the type of transportation patients take to your office. It’s probably more comfortable to wait outside sitting in a car than standing on the street (for those who walk or take mass transit).



  1. Physical actions to reduce the risks of COVID-19:


The following are some conservative suggestions.  You should assess the wisdom of each idea for the setting in which you practice and for your own risk tolerance.


  1. Wait until you are fullyvaccinatedand only see patients who are fully vaccinated. You may want to determine if it’s legally discriminatory to require vaccinations if your patient is too young to be vaccinated or objects on medical or religious grounds.


  1. You may want to tell your patients not to come in-person and do an online or phone session when they or the people they live with have COVID-19 like symptoms(fever, loss of smell and/or taste, breathing difficulties, fatigue). You may want to take patients’ temperature and/or do a symptom checklist upon arrival to your office. Please note that symptom screening will not help detect anyone who is asymptomatic, presymptomatic, or tends to deny or minimize their symptoms.


  1. Some of us think that masksare no longer necessary if you and your patient are vaccinated.  Some of us still recommend masks with vaccinated patients.  Some are allowing patients to unmask in session but require them to mask when they enter and exit the building, use the waiting room or bathroom.  Some ask patients to have a mask handy and quickly put it on when they are about to sneeze or cough.


  1. You may want to continue maintaining physicaldistance with your patients. This includes when they are entering and exiting your office, lying on the couch, sitting in a chair, or playing with you.


  1. You may want to continue frequent handwashing.


  1. Therapists who have office windowsmay want to leave them open during their sessions and workday. The influx of outdoor fresh air decreases the chances of spreading COVID-19. However, it may create problems with confidentiality, street noise, and cold or hot weather.


  1. You may want to eliminate your waitingroom. If you maintain a waiting room, you may want to remove some of the chairs to reduce the number of people in your waiting room.  Some are removing waiting room magazines, toys, and water fountains.


  1. Although COVID-19 transmission is believed to be airborne, some of us are still recommending that you ask patients to avoid using the bathroomin your office.


  1. Even though COVID-19 transmission is believed to be airborne, some of us continue to advise disinfectingdoorknobs, intercom buzzers, bathrooms, and waiting room and consultation room furniture before and after each patient. This may necessitate not seeing patients back-to-back.


  1. You may want to avoid physicalgreetings, such as handshakes, as a way to maintain physical distance.


  1. HEPAair filtration machines may reduce the risks of spreading COVID-19 by sanitizing the indoor air at a reasonable financial cost. A modern building might attempt to reduce these risks by upgrading the entire HVAC system for all the tenants. Ultraviolet light systems are usually seen as an unnecessary step beyond what is required and a cost prohibitive measure. Creating an office with negative air pressure is probably not possible and is believed to be an even more unnecessary step and even more costly than UV light.


If you use any of these devices, it’s important to consult with experts to get the right equipment for your office and waiting room. Installing a small HEPA air machine, that doesn’t perform the required number of air changes per hour, will not reduce the COVID-19 risk. Installing a proper HEPA air machine, that performs the required number of air changes per hour, will stop reducing the COVID-19 risk if it isn’t maintained. This equipment requires regular testing and service to replace filters and ensure that it’s doing the job. Keep in mind that some of these machines create noise that may interfere with you and your patient hearing each other.


  1. Since COVID-19 can spread in all directions – from patient to patient, from patient to us, from us to our family, from our family to us, and from us to our patients – you may feel an obligation and/or it may be required by your local public health law to participate in contacttracing. This should be discussed with your patients prior to beginning in-person treatment. You can explain that you would only give officials a list of names and contact information of who was in your office on a certain day or week. Although you would not say why anyone on the list was in your office, it does place a limit on confidentiality.


  1. You may want to have patients and the parents of minor patients sign an informedconsentfor in-persontreatment. It should explain the COVID-19 risks of in-person work to them and their family, the above changes in how you will be working, and the changes to confidentiality with contact tracing.


  1. You may want to have patients and the parents of minor patients sign an informedconsentfor onlineor phone treatment. It should explain the rationale, advantages, and disadvantages for tele-treatment.


  1. Follow all guidelinesfrom your subdiscipline.


  1. Follow all city, county, state, and federal lawsand regulations.