Author: Melonie Bell

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

 

 

The Boulder Tragedy

Posted on by Melonie Bell

Karen Mohatt, March 24, 2021

A day after the latest shooting and tragedy in Boulder, CO I was thankful to still be home-officing because my office is only 4 blocks from that King Sooper’s Store.  I used to go to the Starbucks located inside for coffee or tea.  Boulder does have a small town feel to it, much like Lincoln did as well.  Boulderites think of themselves as living in a bubble of peace, love, care of the environment, conscientiousness of health, and are very forward thinking.  But Monday, the bubble burst as unbelievable horror visited the city of 100,000.

All day Tuesday, my patients spoke of shock, profound grief, sadness and deep fear.  But most troubling was how they didn’t speak of disbelief.  Rather, they spoke of the violence in our country becoming as prevalent as Covid-19.  Most everyone follows the public health guidelines, with the exception of some, and are now grateful they’ve received or will receive the vaccine.  But yesterday they kept talking about fears of violence and being unable to inoculate themselves against it.  I’m sure I will hear much the same from my patients today and tomorrow.  They fear violence from external sources and we will at some point have to talk about the violence they feel internally as well, as their own peace and safety has been stripped away in one horrific act.  Those with a history of significant trauma who work so hard on a daily basis to feel some semblance of safety, have once again been activated by this tragedy.

By the time I finished with my patients last night, I found myself literally sick to my stomach.  Though working through Zoom, every emotion my patients felt was just so palpable, and I could feel the pain they experienced in the wake of such trauma, and my own vulnerability in the aftermath of such senseless tragedy.

Karen Sharer-Mohatt, PsyD Psychoanalyst

On the Intersectionality of Racism and Sexism

Posted on by Melonie Bell

Jill Savege Scharff

 

I am sitting in my home office, in front of my Zoom screen, where I sit often these days.  But today is a special day.  I am attending an IPI virtual conference that is timely and of much importance to therapists and psychoanalysts.  The conference is called “Be Thoughtful and Act: Confronting Systemic Racism Inside and Outside our Minds” from October 9 – 11, 2020.  Kirkland Vaughans, Earl Hopper and Beverly Greene spoke yesterday about the disadvantaged education of Black children, the need to recognize the impact of the socio-political unconscious on self-perception and behavior, and the constant state of alert in which Black people live.  Now it is Saturday morning and I am listening to Dr. Greene again, and then to Dr. Wolfe, on the topic of the Intersectionality of Racism and Sexism. I want to share a few of their comments and personal reflections that meant the most to me.

Dr. Beverly Greene via Zoom

Dr. Beverly Greene, Professor of Psychology at St. John’s University, entered the screen and began with the history of feminism.  Architects of the women’s movement for equality were White women who were successful in getting the right to vote in 1920. But for Black women, suffrage was mainly theoretical until the Voting Act of 1965. In the second wave of feminism, the focus was on the woman’s right to work.  Dr. Greene pointed out that the pioneering White women ignored the history of Black women who had always been viewed as workers, regardless of their sex.  Some Black women have internalized racist sterotypes about themselves.  Many of them feel compelled to fit the image of the tireless, uncomplaining, subordinate worker who has to be strong, silent, and resilient.  In therapy, they may present with difficulty in claiming attention for themselves instead of always putting others’ needs first.  The late psychoanalyst Cheryl Thompson called this moral masochism.  But in human terms, what we see is that these Black women exhaust themselves from caring for others to the point of depletion, thinking that Black women are supposed to be strong and resilient, bringing in income and raising their children, constantly teaching them how to avoid trouble, and how to stay alive when extra-judicial lynchings, brutal brutality, and demoralization are rampant in insane society.

Dr. Greene told a story about herself and her mother. Dr. Greene grew up in Northern New Jersey of parents from the deep South at the time of American apartheid.  Like millions of other Black Americans, her parents became refugees from domestic terrorism and were part of the Great Northern migration of African Americans from the deep South into Northern and Midwestern cities. Beverly Greene and her family visited her mother’s home in Southern Georgia often.  On one trip, the train had a problem, and so they had to stop for repairs in Jacksonville, Florida.  At that time, the station was completely segregated from bathrooms to convenience stores, with signs saying “Niggers will not be served.  Whites only” right next to signs saying “Coke is 10 Cents.”  The 10-year-old Beverly was furious.  She said, “That sign says Coke is a dime and I have a dime, I’m going in there to buy a Coke.”  She got very loud, and her mom gently said, “If you go in there, those people will not serve us. You can’t go in there.”  Her mother agreed that it was not fair, but explained, “We can’t go in to those places, and don’t think of calling the police, because they will hurt us. We are not going to get hurt just to buy a Coke. For the sake of a coke it’s not worth it.”  Beverly knew she was trying to be disruptive.  Her childhood tantrum was not only that of a child who wanted a coke.  Her outrage was about inequity and even more about its acceptance.  She was most angry that everyone was walking around in that station as if it was perfectly normal.  Her mother understood and accepted that Beverly was angry and wanted to do something.  So, she told her child that it was alright to be angry, but taught her not to go up against a stacked deck.

Dr. Harriet Wolfe via Zoom

Dr. Harriet Wolfe, President-elect of the International Psychoanalytical Association, and former President of the American Psychoanalytic Association, came on to speaker view next.   She talked about her own history in order to model the importance of our looking at ourselves and recognizing racism and other forms of prejudice in ourselves before we can effectively guide others, whether socially or clinically. She described her youth as a child going to a private school and a women’s college. Her Whiteness did not strike her as a problem back then.  In those days, she was more aware of sexism as a problem for her.  Growing up in her family, the daughter had to be protected from behavior that her brother was allowed.  Moving from liberal arts education to medical studies, she experienced sexism when she lost the support of her father who did not approve of her choice of career, her politics, or her being outside his control.  As a medical student sexism was reflected in her having to take breaks in the nurses’ lounge not the doctors’ lounge. This meant she did not have access to informal medical teaching which male students gleaned from locker room conversations with their mentors.  Prior to starting medical school, she had worked with and become friendly with a childcare worker who was Black. She had trouble understanding why her friend never invited her to her home though it was possible for her friend to come to her home.  Dr. Wolfe realized that her colleague lived in a Black community where she could not welcome Dr. Wolfe.  It was a painful experience of racial boundaries. She continues to regret that race remained an unexplored problem between them. Her psychoanalytic training, where the teaching was still based on a one-person psychology with a focus on the internal structure of the patient’s mind, did not draw her attention to her Whiteness and what it meant.  Modern psychoanalysts now think of psychoanalysis occurring in a two-person field in which patient and therapist interact in a mutually influencing relationship.  They also think about transgenerational transmission of trauma and the influence of internal objects on behavior, perception of others, and relationships.  Thanks to psychoanalysis, Dr. Wolfe became able to understand her father’s point of view, stemming from his history, as well as the impact of a racist culture on her upbringing.  Now that the entire psychoanalytic community is dealing with the traumatic impact of systemic racism, Dr. Wolfe is viewing her Whiteness quite differently, as an inter-racial and political challenge to be contemplated in dialogue with diverse others.

 

Reflections of the IPI Weekend Conference by Dra. Iraira Butcher 

Posted on by Melonie Bell

Be Thoughtful and Act: Confronting Racism Inside and Outside of Our Minds
Reflections of the IPI Weekend Conference by Dra. Iraira Butcher 

 

After finding much needed containment in the approximately biweekly town hall meetings with IPI and after the recent escalation in my frustration due to my inability to find a space to explore racism and discrimination in my country of residence, I was more than eager to participate in IPI’s weekend conference with the appropriate title of Be Thoughtful and Act: Confronting Racism Inside and Outside of Our Minds. I constructed a fantasy around my expectations for the conference thinking along the lines of Michael Jackson’s song, Heal the World. This fantasy held me through the latest rejection that I experienced when trying to explore these topics within an institution. In fact, the fantasy grew bigger and then frightening due to my ever-growing thoughts that I was going to be met by the persecutory resistance that has plagued the human race.

But I was pleasantly mistaken.

As I sat with an international community of analysts, psychotherapists, students, mothers, fathers, sisters, brothers, daughters, sons, whites, blacks, Hispanics and Asians, but most importantly, with human beings, to listen, to explore, to analyze, to learn and to understand, I quickly realized that part of the task that millions of human beings have set out to do, inside and outside of IPI and inside and outside of our minds, is to find, pull out and to deconstruct ideologies that have been so deeply rooted, in the DNA, in the unconscious, in the culture, in the psychic structures of humans of all backgrounds but also in the overall society that was built off of slavery, that as K.Vaughans’ said, gave birth to racism.

But it has proven to be a difficult task.

This brought to mind the fear of annihilation. As a black woman born and raised in Brooklyn, New York, I understand that, contrary from what some theorist may say, this particular fear of annihilation is something real and it continues to live strong, throughout an entire life, to include transgenerational , within afro-descendants and the other oppressed communities all over the world. But again, in contrast to what others may say, this fear of annihilation is not a fantasy, it is in fact a reality as it was eloquently exhibited by Dr. B. Greene’s reading of the thoughts written out by a black, COVID-19, frontline New York City Doctor during the weekend conference.

But it goes both ways.

The fear of annihilation is also experienced in the white community both as a fantasy as well as a reality. What I witnessed and experienced during this conference, within the white participants, either because of race or lighter skin color, is a collective shame and guilt not only for what was done in the past by them or their ancestors but because of their inability to deconstruct the ideologies that were imbedded in their unconscious, that was floating in their pre-conscious and that were ignored while in their conscious. In other words, the shame, guilt and resistance related to the difficulties in examining their own psychic functioning, in particular within members of the psychoanalytic community, the examination of their ego. It is important to note here that if therapists are unclear and untouched within themselves, it is more likely than not that there will be a parallel process within their patients.

But it is painful.

Our psychic structures are filled with defenses to counteract and to resist the pains that are associated with, in this case, racism. A few that were highlighted in the conference were denial, repression, projection, displacement, rationalization, reaction formation and intellectualization. Aside from defensive mechanisms, the conference brought forth a space to explore psychoanalytic theory and its strong attributes for understanding racism. Thoughts were discussed in abundance and emphasized such as K. Vaughans’ considerations on education and African Americans in the USA (school to prison pipeline), B. Greene’s and H. Wolfe’s personal and clinical contributions to intersectionality of racism and sexism, E. Hopper’s research and developments on social unconscious, M. Klein’s schizoid-paranoid and depressive positions, S. Freud’s views on mourning, D. Winnicott’s work on cultural experience and many others.

But, as expected, these discussions opened up many more unconscious doors.

The groups, both large and small, encouraged the participants to view racism from distinctive perspectives. This task stimulated me to examine my internal and external worlds thus allowing me to look more at the reality of the situation, which includes the fact that racism and discrimination is a painful topic with limited language to use as expression when describing it as it relates to oneself and to the other, internally and externally, individually and socially and particularly in the white communities. Semi-successful attempts were made to define or redefine terms such as microaggression, whiteness, white privilege and racism in and of itself, by including aspects such as greed, exploitation, narcissism, avoidance, loss, control, secrecy and many others.

But the reality is that there is no real plan to continue to address this topic in the future.

Interestingly enough, the topic of dreams and nightmares was introduced on the last day by C. Ashbach as a means to find ways to unlock the secrets that are kept inside of our unconscious by the resistance associated with addressing and confronting racism. There is no surprise that I had a dream and I was able to share it in my small group. The only thing that I could and can remember of the dream was that my mother was running for President. After exploring my own associations, that included the reality of the fact that we are in one of the most important elections in history, I determined that I saw partial objects in my mother such as my 14-year-old daughter, the resilience and perseverance that my mother had and that was passed down to me and that now I am passing down to my daughter. I was and am clear that, for one, my mother is deceased. Additionally, my mother could not run for President due to the fact that though she was a citizen of the USA, she was born in the Republic of Panama. I was and am clear that because of my career path, I could and can but do not want to run for President. I was and am clear that my daughter can in fact run for President, especially because of all of the opportunities that my husband and I, a black couple, are able to provide to her. It is important to note here that opportunities include psychoanalytic treatment, high quality education, a nuclear family that includes both parents and overall stability. What I didn’t know and realized after an interpretation by C. Ashbach was that I am very visible in the dream not by way of running for Presidency in its literal sense but by way of running the race to uplift the races as a leader. My question of where do we go from here still produces disorganized thoughts, however, one thing is extremely clear and that is that, through listening, as stated by B. Votaw, and partnerships like those produced by the community created in this weekend’s conference, will be the only way to move forward.

Cheers to hope.

participants in the October 2020 weekend: Be Thoughtful and Act-Confronting Systemic Racism Inside and Outside our Minds

Recent IPI Faculty Publications

Posted on by Melonie Bell

Change across a completed analysis assessed using a modified Three-Level Model

Jill Savege Scharff & Pat Hedegard

The authors present their design for a clinical teaching exercise to study transformation in psychoanalysis. They chose a completed analysis from which to select the sessions retrospectively so that the clinical review exercise would not influence ongoing analytic process. The co-authors selected three tranches of clinical material, a few years apart, to be presented by the analyst. They studied the material with colleagues in the impressionistic manner of traditional clinical review, and then subjected it to more systematic examination, using a modified application of the Three-Level Model (3-LM) for assessing change. Their prediction was that the use of the 3-LM model could amplify the clinical impressions of the individual analyst and provide a way of being more specific about the changes, if any, that had occurred, and arrive at which theories best explained those changes.

The authors gratefully acknowledge the participation of colleagues who engaged in the exercise, the generosity of Paul Koehler, MSW, Charles Ashbach, PhD, and David Scharff, MD, who shared their responses to the three tranches of case material, and the analysand who gave permission for the use of her clinical material.

https://doi.org/10.1080/0803706X.2020.1743879

The use of a simple writing task to enhance psychoanalytic education

Jill Savege Scharff & Caroline M. Sehon

The authors describe a simple recurrent writing task called the “Two Page Paper Exercise,” designed to enhance candidates’ learning of analytic theory and technique. They set this task in the context of other analytic institutes’ writing programs and show that this exercise is unique. Their educational philosophy is that, as candidates confront multiple perspectives in contemporary psychoanalysis, this writing task develops their ability to conceptualize, reflect on their learning, integrate affect and cognition, and express their ideas to others in written form and in discussion with peers. The candidate group develops cohesion that reduces writing anxiety. As individuals they develop a writing habit that supports the eventual duty to develop the field of psychoanalysis through publishing. The authors present raw data from candidates’ writing for readers to make their own assessment of the usefulness of the task as a measure of candidates’ integration of learning, development of analytic sensibility and synthetic capacity, and communication of experience and ideas to others.

The authors gratefully acknowledge the generous contributions of Flora Barragan, Ryan Garcia, Stefanie Minen, Andi Pilecki, Matthew Rosa, and Karen Sherwood of the International Institute for Psychoanalytic Training.

https://doi.org/10.1080/0803706X.2020.1718751

Some thoughts about the transition to an online weekend conference  

Posted on by Melonie Bell

Jill Savege Scharff

Because of physical distancing to combat COVID-19, the International Psychotherapy Institute (IPI) moved its April weekend conference on sex and gender and its student graduation ceremony from the usual site in Rockville to IPI’s 1000-capacity Zoom room online.  I thought it was a good decision, and I planned to be there.  I had attended a number of online Town Halls and was quite used to seeing all the attendees in their electronic squares in gallery view across multiple screens, or a large image of a single person in speaker view.  However, in the week before the conference, I was still thinking of scheduling enough time to drive up to Rockville.  I was still anticipating meeting colleagues in the flesh.

Once the conference began online, I resonated with comments about what people were missing – the time after the session to meet and greet in the hallways, the pleasure of embodied presence, giving a hug, comforting someone who had lost a friend or loved one.  Electronic social time was scheduled but was barely used.  Once these aspects were acknowledged and mourned the large group seemed able to work.  Members got used to entering their requests to speak on the chat, and the co-chairs held the center, monitored the chat and called upon participants to speak during the discussion periods. One member spoke of his hatred of physical deprivation and of having to look at his colleagues in their little boxes.  It reminded me of the Pete Seeger song written by Malvina Reynolds, “little boxes just the same.”  But each person seemed far from the same to me.  The variety of backgrounds and size of image within the frame reflected the personality of the person within.  To me, the online setting offered one great improvement.  Instead of looking at the backs of heads as people addressed the speaker or the panel in the Rockville hotel, I was looking at faces, and I could see everyone perfectly.  Although it is a 2-D image, the speaker view brought me very close to a real live person, perhaps because of the size of the image, but more likely because of the affect being expressed.  We broke into assigned small groups five times during the weekend, each group using its facilitator’s own Zoom room number, and that worked well.

People speak a lot about being fatigued by the effort of being online all day.  I felt fine on Friday.  By Saturday the relentless pace had got to me.  I needed to take part of the afternoon off to relax, get some exercise and fresh air.  I missed a presentation that was important to me, and then a small group.  Missing those was a loss I had to take because the conference schedule was too tightly packed for me and for many others.  During the conference, I got an email announcement of a conference that was to have been in Panama in October would now happen online instead. I had intended to go because of wanting to work with my colleagues in Panama, but now I faced a choice: do I want to attend a conference online in three languages?  I tried to tell myself that it will be easier to listen to just the English translation without having to tune out the language of the presenter and the interference from other headsets, and cheaper than traveling to Panama.  But for me it would be so much less enjoyable because of my particular attachment to the place and the people.  If this notice had not come in the middle of a packed conference schedule, might I have responded with more enthusiasm?

This bears on the decision I must make about attending the APsaA conference in June, now also online.  IPI’s director is asked to help ApsaA plan for that transition.  It is an honor for IPI to be recognized as having experience in reaching across a distance.  So, I should want to attend, but I am not drawn to it.  What had drawn me to IPI’s event was the subject matter, the conference design, and the object relations analytic perspective.  The weekend was organized on a theme, with participants studying, responding, discussing and developing the theme.

On Sunday, the conference had its first technical glitch.  The director worked feverishly but with an outward appearance of calm as she put in place an alternative gathering place.  Reminded of the old days with frequent technical problems when IPI teaching was frequently interrupted on the old Polycom system, David Scharff felt that current participants now knew what he and those early classes had put with.  Someone offered him “technology empathy”.  Since the director and many of those leading the current day’s events had experienced those days too, they rolled with the punches.  On this occasion, the host-administrator was locked out of the IPI Zoom room.  She could not reach the Zoom representative to arrange for a new number.   It was explained that Zoom had scheduled an update unknown to us.  The director and the administrator worked together like lightning to inform 72 participants of a switch to the director’s own Zoom room number.  The conference start was delayed by 15 minutes to allow everyone to log on, and the schedule was quickly adjusted in consultation with the conference co-chairs and session co-chairs.   We saw a fine example of grace under pressure.  The ensuing case presentation and discussion proceeded smoothly thereafter.

Last came the graduation.  The convenience of the online venue meant that lots of family members and friends from far away could attend. Faculty described the qualities of individual graduates from IPI’s psychotherapy and psychoanalytic training programs.  Students spoke of their experiences of pain, challenge, perseverance, passion, and reward. Lots of congratulations and praise for work well done was mixed in with sadness of leaving behind group members to whom people had become close over two  to four years.  Some were laughing at silly skits.  Others were in tears at the beauty of a song that captured saying good-bye to a friend who would be missed.  True, this graduation was devoid of physical copresence, but there was no lack of affect.  The closing ceremony felt like a salute to psychoanalysis, to a vibrant, sturdy organization carrying on in spite of the corona virus, a demonstration of the life force over COVID-induced death anxiety.

Changes in Frames: COVID-19 and Teleanalysis

Posted on by Melonie Bell

 April 2020

 

Yolanda Varela, PhD, President, IPA Panamanian Association of Psychoanalysis (Provisional Society); supervising analyst, IPA; supervising analyst and graduate, APsaA International Institute for Psychoanalytic Training.

 

Thoughts arising at Town Hall Meeting:

Changes in Frames: COVID-19 and Teleanalysis

 

With so many countries under lockdown to flatten the curve of the COVID-19 pandemic, the frame of life and work has completely changed.  Analysts who always conducted analysis in their private office, now are forbidden from traveling, and must stop practice or continue to see their patients in virtual space, each connecting from their own home. As always, crises bring opportunities for new experiences for us and for our patients.  I would like to address my experience under three headings: the use of teleanalysis, the early anxieties that are stirred in the patient, and early anxieties that are stirred in the analyst.

 

The use of teleanalysis

Unlike some of my colleagues who had never engaged in technology mediated treatment, I had experience to draw on.  I had already completed a personal analysis with an ApsaA certified analyst, and much of it was necessarily conducted using the telephone at first, and later using Voice over Internet Protocol with web camera.  I had had a full analytic training too — but not one that was approved by ApsaA.  Then FEPAL (Psychoanalytic Federation of of Latin America) authorized ILAP (Latin-American Institute of Psychoanalysis) to offer psychoanalytic training in Central America, as a global outreach project of the International Psychoanalytic Association.  When ILAP arrived in Panama, one of its requirements was that analytic graduates like me who had already completed a personal analysis would have to do an extra 200 hours of condensed analysis “in-person”  that is, traveling to the city where our analysts lived, or meeting in Panama with an IPA authorized analyst newly immigrated to Panama.

 

In order to meet the new requirement, I would do the extra hours.  I decided to travel to the United States to resume with my analyst, but what I chose to do with the extra time in analysis was to focus on what is not represented in me, on my early anxieties.  To address these effectively, I decided to continue my required in-person analysis with four-times-a week videoconference technology mediated sessions between trips to the United States.  For me, analysis “in-person” continues to be the preferable one, but at no time were transference and countertransference aspects lacking in the technology-mediated portions of the treatment.  In fact, it was the change in the frame that evoked the very early anxieties and enabled me to analyze them.  This experience gave me confidence in the use of teleanalysis.

 

Now I am analyzing my own patients in Panama in traditional, in-office analysis.  Occasionally I am asked to do teleanalysis.   For this, I establish new rules.  First, I use the most secure and stable platform (in my case ZOOM) and I don’t let the patient decide the platform.  Before each session, the patient receives a link to access the session with a password that only the patient knows.  I explain to analysands that they should look for a private place, where they can recline, similar to the office couch, with the camera on one side and behind them, simulating my position inside the office.  I greet them with the usual greeting, they recline and lose eye contact with me, but if they turn their head back, they will be able to see me.  I think we should stick to rules for technology mediated treatment that are similar to those in use for treatment in the office.  Beyond these arrangements to secure the external frame, I also shift my internal frame.  It was José Bleger’s article on the psychoanalysis of the frame that helped me to develop my technique in teleanalysis, and so help my patients. Bleger asks us to analyze what lies hidden behind the traditional, well-established frame.

video camera

Early anxieties of the patient

During the past three weeks in quarantine because of COVID-19, I have been transitioning my in-office patients to technology mediated psychoanalysis and psychotherapy.  Because of social distancing to fight the COVID-19 pandemic, analysands usually treated in the office must now set up a private treatment space of their own choosing.  At first, the sessions are dominated by worries about getting sick, the loss of social contact, and being trapped at home with children while trying to work. Behind the emphasis on COVID-19 lies the loss of the analyst’s physical presence and the loss of a safe office, which now seems like a uterus from which the patients were extruded.  Having to see the analyst on the screen, and put up with the times that the image freezes as well, the analysand feels as if the analyst is removing affection.  These fears of loss of response and loss of love result from early fears related to the dead mother.  Fears of viral invasion echo fears of the mother’s death drive, drowning the patient’s desire for life.  Feelings of hopelessness, helplessness and lack of trust in agencies that are supposed to protect us (hospitals, government, Ministry of Health) reflect early attachment insecurities, and convey transference to the analyst as an unreliable object.  With the change in frame from in-office analysis to teleanalysis, I have been able to observe the expression of very early anxieties in analysands who were previously seen only in the office.

 

Anxiety of the analyst

Freud’s warnings about the dangers of changing the frame of analysis are echoed by our own psychoanalysts, supervisors and colleagues, especially when confronting any change from the traditional in-office setting to the teleanalytic setting. Teleanalysis is frequently regarded as a transgression. The transgenerationally transmitted superego will have to be somewhat pacified to understand the current situation as a necessary and effective adaptation that brings us the possibility of continuing to work and of countering the guilt of not being able to do more for our patients, a problema that Eizirik pointed out in a recent IPA webinar.  Patients come to us with a fear of death and we receive them with our life drive.  To support our life drive, we need to pursue our own pleasure and part of that  is our work. We will have to continue to be linked to life, taling with colleagues in Town Hall meetings like this, keeping in touch  with friends and family, accepting and not denying reality, but without being suffocated by it.

CORE Student Reflection on French Psychoanalysis

Posted on by Melonie Bell

In preparing to write this blog on our recent weekend exploring French Psychoanalytic thought and its contribution to understanding psychotic and borderline states, I found myself worrying about using too many “I” statements in my reflections. This urge to avoid writing “I” too many times in this composition, I think speaks to the theme and tone of this past weekend. Alain Gibeault described Freud’s theory of psychosis as de-cathexis from worldly objects and the psychotic terror of being engulfed or consumed by an object. Additionally, he discussed the concept of “the blank,” a space between matter and nothingness. We then watched a recording of an institutionalized patient, François, describe murdering an elderly woman, Jeanette, whom he had cared deeply for. He described Jeanette and himself being up on separate pillars with “something growing up between us.” I was struck by the terror of this image, being alone on a pillar, surrounded by the blank, with something terrifying growing up between François and Jeanette.

This material along with Dr. Gibeault’s discussion of psychodrama led into our small group discussions. During our group affective learning, fear and safety and their relation to individuals, patients, our group, and IPI were central themes. As the group went on, I felt myself feeling strangely disengaged and detached.  Initially, I defended myself as bored.  However, upon reflection, like François I was gripped by a psychotic fear of vulnerability, of being engulfed by the group or by IPI.  I too, had in a sense de-cathected from the horror of the material and was existing in the blank.

I’d like to say that the psychodrama of our small group facilitated my re-cathexis with the material, but I found myself struggling to stay focused on Saturday as well.  On Saturday afternoon, a colleague in the CORE program gave a fascinating presentation on a boy that he had been working with. The presentation was rich with symbolic meaning and beautifully captured the theme of terror of being engulfed that was running throughout the weekend. During one of the sessions presented, the boy was playing with a dollhouse. The presenter described this patient arranging the dollhouse in such a way that there was a “sealed off room, full of drawers” upstairs. For the second time during the weekend, I was struck by the rich imagery described by a patient. During plenary, themes of fear and violence were discussed. The ambivalence concerning feeling for and treating psychotic patients, like François, and recognizing the horror of the acts that they sometimes commit. Jill Savege Scharff brought up confronting gun violence, hate crime, toxic partisan politics, and climate change that are terrifying realities of our daily lives. It was during this dialogue that the image of the “sealed room, full of drawers” popped back into my consciousness.

I wonder if my feelings of detachment and the theme of unease that seeped into the weekend conference acted as a defense against the sealed room, full of drawers inside of all of us. I began to think of these drawers as full of rage, panic, lust, and violence, terrifying emotions/drives that are walled off inside me, but in reality would take little to provoke. In relation to my small group: would these terrifying affects/emotions kill my group? In relation to psychotic or borderline patients: does the fear of violence or panic in myself incline me to split them off as different and distance myself from them? In thinking about the didactic material or engaging with IPI: am I de-cathecting at times and existing in the blank in order not to experience frightening emotions? This weekend spent thinking about French psychoanalysis and psychodrama provided the opportunity to think about borderline and psychotic states and the terrifying moods and affects associated with those states as positions along a continuum on which we are all precariously perched.

 

Thomas Ringwood Jr., NP –  1st year student in 2-year Object Relations Theory and Practice Program (CORE) December 1, 201

Analytic Student Reflection on French Psychoanalysis

Posted on by Melonie Bell

During the November 8th through 10th weekend of 2019, the International Psychotherapy Institute hosted the French psychoanalyst Alain Gibeault. French analytic writing is often criticized by British and American analysts as overly abstract, lacking in clinical detail, and often difficult to follow; nonetheless, Dr. Gibeault’s presentation, particularly the video recordings of his patient Francois – a man who was legally committed to mental health treatment following his murder of an elderly woman during a psychotic break – gave us a first-hand look at how French psychoanalytic thought can be applied in the treatment of people with overwhelming psychotic terror. In Francois’s case, psychodrama was used by Dr. Gibeault and his colleagues to provide a mediator for the patient to begin to make sense of his otherwise unrepresentable mental state.  Rather than applying direct interpretation in an analytic dyad, which is the usual clinical approach in most psychoanalyses, Dr. Gibeault and his team allowed Francois to choose characters among the hospital staff to play out, in real time, the dramas that were occurring in his mind. That part of Francois that killed an elderly woman in his psychosis was re-presented to Francois in a session of psychodrama by an ‘actor-therapist’ who improvised a murderous old woman that Francois ran into while riding on a commuter train.  In another session, Francois’s brother was depicted as a carefree, somewhat envious character with whom Francois could interact – and at as much distance as the mediation of the psychodrama would allow. In this way Francois could experience aspects of murderous rage and envy, as represented by the actor-therapist, rather than having to own it as a direct aspect of himself.  In other words, rather than attempting to understand and interpret to Francois the unconscious derivatives of his intense envy and murderous rage in a two-person analytic relationship – an approach that Dr. Gibeault believed would probably be too overwhelming for Francois given his inherent engulfment and fusion anxieties that lay at the heart of his psychosis – the mediation of the multiple actors in the psychodrama allowed Francois to begin to think about his experience in a way that he could tolerate.

As I reflect on this particular weekend at IPI, I find myself drawn to the idea of the Group Affective Model as a kind of psychodrama.  The Group Affective Model – or GAM group – is a unique aspect of training at IPI that brings to life, much like in psychodrama, the often very complex theoretical and clinical material that participants are trying to digest.  Though not itself a “therapy group”, participants in small GAM groups of between four and let’s say ten individuals, are nonetheless encouraged to bring in their own affective material, often derived from their personal lives or immediate experiences of the weekend. By interacting in this way the GAM group works to understand, as a group, the different facets of the material under discussion. As such, what is learned at an IPI weekend is never only theoretical. Rather, it comes to life in some form or another as a memorable emotional experience from which any and all of the members of the group can learn – each in their own way. Given that this weekend was on the terror of non-representative states and the defensive use of psychosis as a way of negotiating the horror of experiencing psychic “nothingness”, it is not surprising that groups would get in touch with psychotic aspects of themselves as a group.  It was so in my own GAM group as well as in others’ groups that I had heard about.  This is not something to be concerned about as much as it is an opportunity to think about, particularly après coup – in the context of the theoretical material being presented over the weekend.

In thinking about the GAM group at IPI, I am also reminded of Dr. Gibeault’s discussion of the necessity of “the director” of a psychodrama (or of a GAM group, or even of an institute as a whole) as a representative of the ‘thirdness’ – or the analytic third – of the group.  The director serves as a container and a mediator, a kind of Perseus’ shield between the raw experience of group members and their distance from the material under discussion. With a good enough “director”, the experience of the psychodrama can be mediated in a way that makes it possible to appropriately reflect upon what is occurring in order that it can be learned from as an experience.  Obviously, there is nothing quite so good as a “good enough” anything. In that way, we struggle, as indeed we did once again this past weekend, to understand the ideas presented during the weekend in the context of our own unique clinical experience as well as in ourselves in ever new and enriching ways. Taken in its entirety, this was once again my experience of an IPI weekend – and one that will remain as my own experience in the learning group of analytic training at IPI over the last several years.

 

Matthew H. Rosa, M.D. – 4th Year Analytic Candidate