Providing psychodynamic care during COVID-19

The COVID-19 pandemic has radically altered how psychodynamic clinicians are using technology to provide safe spaces, intimate connections, and relational continuity. Many clinicians have had to replace reflectively considering technology use through intentional planning and communication with patients with a required, rapid conversion to full-time telehealth. As a result, practitioners may be feeling uncentered, unprepared, vulnerable, and frequently exhausted.

To help psychologists practicing during this time, the Society for Psychoanalysis and Psychoanalytic Psychology (Div. 39) offers this advice on providing psychodynamic treatment.

The shared traumas of the COVID-19 pandemic have personal meaning. Psychoanalytic care includes attention to both collective distress and individual suffering. Everyone experiences grief over a lost way of life, struggles with unfamiliar daily routines, and fears about a radically uncertain future.

Having the humility to witness and commiserate with these shared experiences without fantasies of fixing the problem can provide patients some comfort. At the same time, along with continuing to address the problems that brought someone to treatment, psychoanalytic care in the pandemic also includes exploring the personal triggers and vulnerabilities complicating shared fears and losses.

Understanding how past suffering informs today’s can help decrease the harshness of current experience.

The safety, privacy, comfort, and reliability of a psychologist’s office setting helps create a therapeutic “holding environment.” In its absence psychotherapists should build a telehealth-specific treatment frame (PDF, 116KB) that addresses those issues.

Creating privacy while everyone is working or doing schoolwork at home presents unique challenges. You or your patient may have to conduct sessions in your garage, for example, away from family members.

Initial decisions need to be made about phone or video and what platform to use. Keep in mind that the treatment frame could change based on what’s working, or not, for a particular therapeutic relationship.

Many psychodynamic clinicians report being unusually tired after a full day of on-screen appointments. There are many reasons why this is the case, including the demands of attention, empathy, and relational dissonance.

Attention

Feeling present with one’s patients on screen, i.e., an experience of “telepresence,” requires focused attention on the technologically-mediated representation of the other while purposefully avoiding all the potential distractions in one’s immediate environment, like a bird flying by your window. Fighting distraction is a special challenge if you look away from the screen to move your eyes as you would in person in search of space for imagination and reverie.

Some find having their own image on screen a useful reminder of how the patient is seeing them, while others find it a distracting trigger for anxious vanity and prefer to turn their own image off. If it’s too hard to stay focused, consider switching to telephone or use audio-only on your computer.

Maintaining “telepresence” also requires effort to not wonder about, or even check, emails, texts or social media messages lurking in the background of the computer or phone you are using.

Empathy

Shared embodiment feeds empathy. In the absence of automatic and intuitive processes like implicit imitation, affective micro-attunements, and mirroring, it takes more work to find the other’s inner experience.

The limitations of screens make empathically connecting much more difficult. While you get to see aspects of patients’ lives previously only discussed, that doesn’t make up for the extra effort empathic immersion requires on screen.

Relational dissonance

Even when attention is optimally focused and empathy achieved, with telehealth there is also a dissonant physical experience lingering in the background. The body knows it is sitting alone in the absence of the other. Resolving that relational dissonance takes additional effort.

Staying meaningfully connected and maintaining an attunement-based bond is still the goal while practicing telehealth. But there is a risk that in the stress of remote connection, patients and therapists may want to avoid potentially upsetting topics and interactions that might threaten the fragile connection telepresence affords. This can lead to a collusion to avoid the traumas, conflicts, and dissociated experiences that brought the patient to treatment in the first place. Understanding what telepresence affords can minimize this risk, and resources are available to help.

Technology will be a constant third presence in the treatment. Technology failures like dropped connections; pixelated, blurred, or frozen images; distorted sounds; sound and image falling out of synch are ever-present possibilities. When glitches occur, it is helpful to acknowledge and discuss them, rather than just soldiering on with the session.

Technologies also intrude when working smoothly by introducing noise, distortions, and other mediation artifacts. These alter the emotional expressions subtly present in conscious and unconscious communications making it more important than ever to nurture therapeutic humility.

Consider making statements like “if I’m hearing you right” more frequently. There is therapeutic value in recognizing we share with patients the intrusive presence of technology as part of living through the pandemic.

With boundaries between home and work dissolved during lockdown, building time for mindful self-care is especially important for psychotherapists.

Movement and exercise throughout the day give your body a break from your static device-specific positions. Being outside also helps, whether it’s a masked, socially-distant walk around the block or accessing nature.

Keeping connection with friends and family while making time and space for silence, solitude, and recalibration are crucial. Finally, receiving support and offering it to your colleagues is helpful, whether informal or organized.