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.

 

For Some Psychotherapists, the Work Has Always Been Virtual

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

 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

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

Recent IPI Faculty Publications

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

Changes in Frames: COVID-19 and Teleanalysis

 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.

In Remembrance: Alice Brand Bartlett, Ph.D.

 

Alice Brand Bartlett, PhD

1950-2019

 

 

Dear Faculty, Students, & Friends of IPI,

Alice Brand Bartlett was a beloved adjunct faculty in the International Institute of Analytic Training, a sensitive and thoughtful supervisor, a supportive mentor, and a valuable friend to many of us at IPI. She died on July 13, 2019 from ovarian cancer. Those of you who knew Alice can rightly imagine that she was lively until the very end, fighting to survive and to continue in a profession she loved so passionately.

Alice was born on October 27, 1950 in Carrollton, Missouri. She pursued an MS in Library Science and became Chief Librarian of the Menninger Professional Library. At Menninger, she held many prestigious posts, including Associate Dean in the Menninger School of Psychiatry. She went on to pursue training as a psychologist and psychoanalyst, at the Fielding Graduate School and Topeka Psychoanalytic Institute, respectively. The American Psychoanalytic Association affirmed her status as a Training and Supervising Analyst in 1996. We all benefitted from her library science expertise, as she became Board Director for the Psychoanalytic Electronic Publishing database (PEPWEB), awarded the Sigourney Award in 2018. Just before her death, she served as Director of the Greater Kansas City Psychoanalytic Institute.

While all these accomplishments speak to her intelligence, generative contributions, and respected place in the field of psychoanalysis, most of us knew Alice as kind, compassionate, humorous, spunky, and a bit irreverent. She was devoted to her patients and mentees, as is evident in the way she approached the end of her work with them, conveying genuine care and respect and regretting the loss her death would impose. For IIPT, she was one of our most active adjuncts, facilitating clinical case consultation, providing supervision and analysis, and serving on the ethics committee.   We miss her already!

Alice leaves behind her husband Tom and many friends and family. A public memorial service will be held on Saturday, August 17th at 11:00am at the Chapel in Mount Hope Cemetery (17th and Fairlawn). In lieu of flowers, please make memorial contributions to The Greater Kansas City Psychoanalytic Foundation, Greater Kansas City-Topeka Psychoanalytic Center, 1000 E. 24th St., 4E-53, Kansas City Missouri or Col. Potter Cairn Terrier Rescue.

Homage for Asbed Aryan

The members of the International Working Group on Teleanalysis hosted at the International Psychotherapy Institute were sad to learn that Asbed Aryan, who seemed to be getting better, had suddenly lost his fight with cancer. Asbed was such a kind, generous man, which came through so clearly in his clinical work.  He was a devoted training and supervising analyst who pioneered the use of technology in distance analysis with a candidate in Armenia, and the author of books on adolescence such as Clínica de Adolescentes co-written with Carlos Moguillansky. We knew Asbed as a committed participant of our International Working Group in Teleanalysis since its inception many years ago, enthusiastically participating from Buenos Aires with his dear colleague Liliana Manguel in our monthly online meeting, faithfully contributing to our meetings even amid treatments for his illness.

Asbed with teleanalysis groups
Asbed with Teleanalysis groups

 

We first met Asbed in Chicago when separate interests in teleanalysis brought us together for an IPA Congress panel on teleanalysis. Our separate proposals were joined, continents were bridged, and the resulting panel was presented with simultaneous translation and chaired by Charles Hanly. Since then we’ve collaborated successfully on shared proposals for IPA precongress workshops held in Mexico, Boston, and Buenos Aires, research panels, and book chapters, the latest of which “Psychoanalytic Process in Cyber-technology” will be published posthumously in Psychoanalysis Online 4: Teleanalytic Practice, Teaching, and Clinical Research, edited by Jill Savege Scharff (Routledge, October 2018).

We will always remember Asbed’s intensely intelligent contributions from his great experience in this field. What good work he did for psychoanalysis, with great sympathy and devotion for those at a distance from major centers: What fun we had talking half in Spanish, half in English with Asbed at Congress banquets! We remember how much he enjoyed coming with us for dinner at the Cosmos Club in Washington DC. We will miss our loyal friend, and will be holding his family and his colleagues in Argentina and Armenia in our minds and in our hearts in the days and months to come.

In sympathy and affection,

Jill Scharff, Founder, and Caroline Sehon Chair, and members of the International Working Group on Teleanalysis hosted at the International Psychotherapy Institute www.theipi.org

IPI Program Graduates

Congratulations to our IIPT (analytic) graduate Michele Kwintner and our Core (object relations) graduates, and our clinical consultation program graduates.

cake

 

IMG_3633
Suzanne St. John and Karen Fraley announce the names of the Clinical Consultation Program graduates.

 

 

IMG_3620
Graduation Dinner

 

IMG_3638
Caroline Sehon (IIPT chair) Michelle Kwintner (graduate) and Janine Wanlass (IPI Director)
IMG_2874
Two Year Core Students preparing for their last weekend small group as a cohort (Henriette van Eck, Kelly Seim, Steven McCowin, Christie Dietz)
IMG_3619
The graduates acknowledge the support given to them by their group leader (Lorrie Peters)
Core graduates present their group leader with a blanket made of patchwork saris.
Core graduates present their group leader with a blanket made of patchwork saris.