Changes in therapeutic settings during pandemic times
Before Covid-19 pandemic times, therapy was mostly done in-person. The patients visit the mental healthcare professionals in the clinics/centers/consultations rooms on a scheduled time. A session typically lasts from 45 minutes to 1.5 hours. Some psychoanalysts and psychotherapists may consider conducting sessions via phone calls or video calls as an exception. For instance, when the patients reside in areas where psychotherapy is not accessible within reasonable distance. Phone/ video calls may be a viable option, after taking into consideration the issue of safety, benefits of undergoing therapy instead of getting no help at all, as well as its limitations, for each individual patient.
During pandemic and lockdown, except the frontliners and mental healthcare professionals receiving their patients in hospitals and clinics, most psychotherapists, including myself, have had to adapt to offering therapy sessions online. Therapy in a common, shared physical space was abruptly changed, and had to take place in each other’s more private, personal space. The pandemic is already some time behind us, and the clinical thinking about therapeutic settings should have been transformed permanently. Yet, in many consultations, supervisions, and case discussions with colleagues, I am struck by how online therapy is often framed as simply as a matter of the patients’ convenience, or perhaps the therapists’ own convenience and business perspectives, with very little curiosity to what the preference may signify.
Listening to my patients, online
Digital communication that was once deemed a substandard of deep, quality connection and intimacy has become the norm. I continue to listen to how people think and relate to their pain and sufferings. My patients continue to speak.
When we had no choice but to move therapy online, what stood out to me was the way the patients navigate a remote consultation. Compounded by their characteristic speech, they communicated how they too need to renegotiate a form of relations to me, our shared time and space, therapy, and a life of fear and isolation. The entire world was shaken by the brutality of the virus, the language used in public health recommendation was once changed from ‘social’ to ‘physical distancing’ hinting at an attempt to reduce the real, emotional impact of a deadly contagion.
Nothing truly takes the edge off the sense of social isolation anyone could feel then. Expert psychologists recommend maintaining a sense of connection with family members and friends through virtual communication. I think, it goes without saying. Perhaps a more containing recommendation would be to encourage a sense of acceptance for the reduced quality of social connection for the sake of safety. For those who have to cram under one roof with their family members and housemates whom they feel suffocated interacting with, the recommendation was on focusing on achievable self-care and asserting boundaries.
For some, virtual communication, that is thought to be an acceptable alternative to actually sharing the same physical space, falls far less than ideal. It does not speak to the quality of human connection individuals seek. Families, couples, friends find the lack of physical company unpleasant, if not unbearable. To make it up via video calls sometimes stirs up the overwhelming sense of longing, sadness, grief, and helplessness. At times, for patients struggling with intense feelings, the only way to not feel these feelings is to avoid communication and connection altogether.
What exactly was lost in the transition from physical to the adjusted, virtual settings, remained rather vague, for at least a few months. What came up though, were rich clinical materials. I began noticing how each patient navigates their therapy space, when they have more control. A therapy space, which to myself as both a therapist and an analysand, is supposed to be private, safe, and sacred. However, I have learnt that many patients beg to differ. Some patients relaxed on their “dress code.” Some signed in and out of the virtual waiting room a number of times. Ending any session by closing the virtual meeting room and hanging up can sometimes felt to be cold and abrupt. Some were obviously preoccupied with their “self-views.” Some required repeated reassurance that I can actually hear them well. What each patient allowed in any session into my view of their bedroom had then become part of the unspoken materials they brought in for the day.
Where is the body?
Post-Covid-19 era, I work with some long-term patients towards returning to the actual consultation room. Many potential clients who reach out prefer to have physical sessions. Some demands for online sessions, to conveniently be squeezed in to their hectic schedule, rather than being considered as an event or activity that they would anticipate, prepare, participate more actively, and leave time out to reflect about aftermath.
In my own clinical work and discussion with colleagues who work with adolescents and young adults, the emerging pattern is that the younger generation no longer differentiates the virtual from the physical world. They develop their identity and a sense of others by immersing themselves in the digital world. This is the group of people who is more open to getting therapy. They are the group of people whom any therapist trained previously and today will have to face and listen to. They hold a very different idea of self and intimacy. For them, a digital relationship is not simply a cheap substitute for a physical one. They are redefining what it means to be a person and in relations to others, pushing conventional boundaries, forcing the psychoanalytic practitioners to rethink their treatment/ analytic frameworks and concepts of self, intimacy, connection, and detachment.
Above all, online sessions present the inevitable question of “What about the body?” In therapy modules whereby thoughts, cognition, consciousness, and intellectuality are main focus of work, the emotion and physical symptoms are also often reduced to just those that are named, identified, thought and talked about. Physical or virtual therapy makes not much difference to the therapist-patient pair. Reflecting on my own analytic training and participating in case discussion with colleagues who do not engage in psychoanalytic practice, I see how the body is often excluded from therapy and treated as something that the individual patient needs to take care of, with medication, more rest, more relaxation techniques, behavioral experiments or pleasurable activities that one needs to take initiative to schedule, perhaps with the support system. The non-analytic therapist addresses just the motivation, the lack of self-help skills or techniques, and the unhelpful thoughts and belief systems that deter the patient from actively participating in life. The non-analytic therapy neglects as they refuse to look into how the way a patient relates to therapy and the therapist, the way the patient honors or devalues the therapy hour, the way the patient makes time to travel from home/ workplace to the consultation room and then makes their way home, may all well reflect in a subtle, unconscious way the way they perceive themselves, how comfortable and effortful are they in protecting their healing and personal growth, and the way they learn by allowing adequate time and space to prepare, sink in, and reflect with the therapist.
The settings is part of ethical analytic treatment
We survived the pandemic, and have more or less adapted to the “new norms” but for the reflection about therapy settings continues.
The dissimilarities, “third,” “otherness,” gap, and ambiguity heighten. How do two persons in different spaces connect? How do two minds and hearts communicate? While we speak the “same language,” how do we with different experiences, minds, and bodies come together to listen to what is being said or not said? How do we grapple with misunderstanding, obscurities, and nuances in the speech, experience, or action?
Most people attend therapy bringing problems that they are aware of, but there’s much more that’s unspoken and awaits verbal expression which then is open up for examination, working through, and discovery. What cannot be said is then manifested in the behaviors and symptoms that seem nonsensical and random. While one may worry about what can you contribute to the therapeutic relationship or what do you want to say to progress in therapy and life, my questions for most people would be “Are you truly curious about you? Yourself? Your speech?” and “Are you willing for us to grapple with the frightening unknown?” Most importantly, your body may be speaking its own language, awaiting attention, not to be silenced or rectified, but to be integrated into a richer sense of being alive.
