Psychoanalysis During A Pandemic

I will discuss the challenges of providing group and individual psychoanalytic treatment during the pandemic. There are transformations in the form and content of the sessions. First of all, there is the moving from offline to online individual sessions and the emergence of online therapeutic groups. Then, there are the increasing themes connected with COVID-19.

In this paper, I describe my own clinical experiences during the pandemic, and about widening the psychoanalytic frame in this anxiety-ridden time.

The COVID-19 pandemic in Kazakhstan is part of the worldwide pandemic. The virus was confirmed to have reached Kazakhstan on 13 March 2020. On 15 March, the President of Kazakhstan declared a state of emergency from 16 March to 11 May 2020. On 30 March, many cities were under lockdown.

The reality forced us to respect ourselves. We could no longer see our patients and supervisees in person. We were faced with a choice: either cancel sessions until the unknown end of quarantine or switch to online sessions.

Fortunately, I already had two decades of experience in holding sessions via Skype, and in 2013, I wrote the paper Psychoanalysis Using Skype. ¹ Since then, "a lot of water has flowed under the bridge".

At the beginning of quarantine, I used Skype because it was familiar to me. Now I have to switch to Zoom because of technical troubles. Skype was good for individual sessions but not group work. Everybody from a therapeutic group could change mode on Skype, not due to their resistance, but because they were just beginners and didn't know all the Skype rules. Secondly, if someone had a bad Internet connection, all the group suffered from the inconvenience. Zoom was better because only the organizer could manage it. If someone had a bad Internet connection, only they felt that discomfort and the group went on without interruption. Thirdly, the possibility to set up a virtual background allowed members to attend the sessions from anywhere: a kitchen, a hall, a bedroom and another consulting room while my room was being renovated, or even a hospital if you fell ill.

After thinking and rethinking, I prepared and sent a letter to every patient, every member of the therapy and supervision groups and suggested that we online work. Almost all the individual and group patients agreed to use the Internet. Once they did, I sent instructions on how to work online. (See attachment 1)

Even P., being an ardent opponent of online sessions, who refused for many years to use the Internet during my or her trips, gladly agreed to move to online sessions. We still joke about that new “desire” of hers. However, the pandemic helped her to be more flexible and to be prepared for unexpected changes.

My long-time patients were already ready. They had worked online with me during my, or their, vacations. New patients and group members had to work on the technical aspects of the new model. They set up Skype or Zoom and looked for a secluded room with windows and doors closed.

Due to the quarantine, the whole family was usually at home, so it was impossible to ensure confidentiality and security. Sometimes I could see a child sitting next to his mother. The mother sometimes may warn me and stand up to change either diapers or a cartoon on TV. Sometimes our session might be interrupted by her husband, her mother-in-law, her toddler etc.

In order to have a more confidential and private setting, some clients with a car would hold their sessions in their car. The interior of their car met all our work requirements, except at night when it gets dark, and the client's face gets invisible. And even here, they found solutions: either they lit up their face with a flashlight or moved to another more illuminated place.

Being closed in studios or apartments, sometimes with no balcony, many patients were unhappy because they felt cut off from city parks, streets, squares, and just open spaces.

Some patients went to their parent's house in the village or even moved there. In sessions, they considered whether to buy a house in a village or start a farm business.

Moving to a village, of course, was an escape from social isolation, or maybe it was an escape from therapy, too. Because in some villages still there's no Internet.

There was always a way for those who wanted to see me. For example, two of my patients would drive to a gas station for their session time, because that's where the Internet connection was. Disrupted connections were mentioned as to why some could only use audio WhatsApp. There wasn't enough Internet power for the video.

There were many anecdotes about how a speaker was dressed below the belly during the online seminar. Yes, indeed, the same happened to me. As if my Super-Ego got more lenient, because sometimes, not always, I might wear sports trousers with an office shirt. I would never dress in such a way if I sat in my own consulting room. Mostly, following the rules, I forced myself to dress as if I was holding an offline session.

I guess it is the same with my patients. Some women could appear online in their dressing gowns. Once a female supervisee turned up in her bath gown. Nobody said anything but next time; she was dressed up in a usual way.

The first lockdown caused angriness; group members refused my proposal on moving online, except one participant. Perhaps, the reason was that participants were not ready for a sudden switching. Then, after two months of quarantine, they were silent, waiting for a reduction of quarantine rules.

Once lockdown ended, all of them came back to my consulting room, feeling happy. So alive, meeting in my office, it seemed as if the group members returned to the old world of accustomed face-to-face communication.

When the new round of strengthening of the quarantine was announced, everybody went online willingly. Only one member left the group protesting.

Patient U: In the online group, I didn't feel people in the same as when they were around, and I could see them as a whole. Later, it seemed that even online group sessions turned out to be no different from offline ones.

It seems, not just this patient but many others preferred to feel and smell a person totally, not a part object.

I was disappointed, too. Earlier I was absolutely against online therapeutic groups. I felt like a trapped wolf. I have heard that the wolf gnaws its paw to escape from a trap. Thus, he saves his life by losing his paw. Therefore, I had to save the group even though I could lose one of them.

Patient R: Now, when our cities do not have strict quarantine, during many online courses, or just communicating with people, I realized that I came back to the long-time forgotten skills to make friends with people from the first moment I have just met them. Maybe it’s because of the group therapy. We learn to meet new members, who join our group, and I can apply this skill in real life.

Even when my old groups rejected the online mode of sessions, I got many requests from new people outside Almaty. I started seeing many online therapeutic and supervision groups. I had to compile a manual for online group work. (See attachment 2) So, the pandemic changed my attitude towards group therapy running online. Now I have enough experience in providing online groups.

A new experience was to combine offline and online modes. If someone from the group was outside the city, I let her attend her group online when other members were sitting in the office. After a while, I was asked to cancel this form of work. It was inconvenient: the group members needed to speak louder than usual to be heard by online members, the online member was partly seen by offline members, someone was left off the screen, it was impossible to see everyone as we could in the consulting room. Shared virtual space was different from a shared alive space.

Some individual patients, too, refuse personal therapy online. As if they accused me of self-interest: Why fear that virus? I am healthy; you have no cough, just you refuse to see me in the consulting room, then I will be the first to refuse. It's like they turned into babies who don't understand the pandemic and/or quarantine situation.

I think the denial of the pandemic, the crisis, also manifested itself in the lack of discussion about this ongoing reality. During the first two months of quarantine, I noticed that my patients spent less time talking about pandemic issues. They were, as usual, preoccupied with their personal issues. Their feelings and passions, desires for love, life and death, are shared in the transference between the analysands and me. As if my patients live dissociated from the pandemic. As if they could not bear to acknowledge real issues. Any word about the coronavirus in the sessions might be mirroring their denial and dissociation of the real situation.

But, as if the reality in our city and country confirmed that absence: The total number of infected people was 5000 out of 18 million, and no one died before May 1. None of my patients, or their relatives, were sick, no one was lying in the hospital, nobody died. The coronavirus was an invisible idea, not a real danger for many patients.

After two months of quarantine, we were given more freedom. So, I met the demands of my patients and let them come to the office as it was before the pandemic. Being the law-abiding one, I created the additional Instruction for working offline for all the patients in our centre. (See attachment 4) The new rules were for our office: regularly wash our hands and wipe surfaces, beginning from the gates to the chairs.

In June, enjoying a short period of a reduction of the quarantine, some patients went to the offices to work. Many patients went shopping, walking. Everybody breathed in freely. Unfortunately, the period of joy was short. By the middle of June, our country had an explosion of sickness and death.

In July, a new lockdown was announced in response to rising case numbers. Then, this lockdown was extended to expire in middle August.

In August, the coronavirus cases in Kz are 104071, 1415 people died, and 87920 recovered.

Since the middle of June, coronavirus and pneumonia cases toughed my patients and their family members. The patients actively discussed new facts of COVID-19 in the sessions. The explosion of virus and pneumonia triggered un/conscious defensive reactions, including obsessional cleaning, counterphobic behaviour, and denial.

F (satisfied): My family now is very seriously prepared for COVID, yesterday we bought lots of vitamins and antibiotic drugs.

A (surprised and angry): Just now? How about March?

F (carelessly): We thought COVID would avoid our family.

Seeing the unreasonableness, carelessness of my clients, I sent a reference to breathing exercises and the opinions of financial experts to prepare for the economic crisis.

The reality insistently came to my consulting room. I was pressed to move from the neutrality rule. I strongly asked clients to carefully calculate their finances, to save enough money for about six months, even better for a year, enough to keep the same standard of living. I repeated that psychoanalysis is not a booby trap; first, one must pay for the communal services and food. I explained that they do not have to live for the sake of psychoanalysis. On the contrary, psychoanalysis is for life.

Obviously, overwhelming affects generated by the real danger led to regression. It seems to me; I take the role of a caring mother, either of my own worries or due to projective identification from my patients. As if the pandemic let me weaken the strong rules the setting was accustomed to before.

Our physical separation from our patients while working online during the pandemic doesn’t prevent moments of intimacy through a screen. The virtual presence of myself as a constant object allowed the patient to process and tolerate her distress and share her doubts and concerns, anxiety and suffering.

I totally agree with the thought that 2020 was the Year of Anxiety. (2) Everyone on earth felt uncertainty due to COVID-19, due to the experience of a global quarantine of unknown duration, due to the financial crisis, due to a life that was very different to the one everyone had planned. Thus, we were alive in a state of high anxiety. For sure, almost every patient would speak and show his/her fears and phobias.

One should have a certain amount of anxiety to survive, to maintain self-protective measures. The pandemic forced an increased degree of health worries about oneself and loved ones, jobs and the economy, the availability and deployment of needed resources, education, and advancement of their children, what life after pandemic will look like.

The members of one family manage the uncertainty that feeds anxiety in various ways. Some seek to reduce fears by consuming the latest information about the pandemic from many sources; others refused to read the news. A sharp conflict may cause stress when two subgroups in a family manage their uncertainty in opposite ways.

As everywhere, the globally imposed home quarantine of families has caused in-house conflicts and neurotic repetitions of unresolved childhood issues. Some of the thoughts I heard during the months of the coronavirus pandemic included: the Covid-19 epidemic is the result of human intervention; Darwin was right quite well; this virus is the consequence of climate change. My patients were happy that rivers have cleaner water that they can see wild birds and animals on the city streets and parks. They blamed their relatives who behaved like ‘hooligans’ - didn’t sit home, visited friends’ parties/ceremonies that were usual for Kazakhs.

Patient K (angry): I hate my parents. They live as if there is no virus, no quarantine. I yelled at them yesterday when they went to a party of their old friend. Why? What for? They want to be infected and die!!

This crisis, with its social isolation, has revealed the significance of loneliness. Some patients of mine believed that they are not isolated as long as they have social media. But then they agreed that loneliness would not disappear due to social media connections. Moreover, the messages, likes, and smiles emphasized the emptiness.

I am sure that psychoanalytical patients have the resources needed to face these challenges. They are not alone while seeing us, analysts. But, the flow of new patients got bigger than before the pandemic.

Patient E (thoughtfully): An interesting point, just the pandemic prompted me to turn to a psychoanalyst faster because during the isolation, there was no one to share negative emotions with, no one to complain to, and those emotions began to eat me from the inside.

The psychoanalytic treatment helped my patients to overcome illnesses easier and faster. An example: a whole department of 7 employees got sick at once. They were hospitalized due to the very hard form of bilateral pneumonia. Just my patient recovered in 5 days. Others had been at the hospital for 2-3 weeks. One of them died.

In July, the theme of death was spoken often. It is obvious that deeper grief is processed after a death during a pandemic where the usual rituals are prohibited — no burials, no big number of visitors. Traditionally, Kazakhs think that the more people who attend the ceremony, the more respect there is given for a deceased one. Sometimes there might be several hundred people. Nowadays, officially no more than 10 people, including medical and ritual staff, may go to the cemetery. Patient H complained that just 19 people came to her father's funeral. Patient J was disappointed because just her mother, nephew and herself were allowed to go to the cemetery to bury her father.

The hypothesis on hidden suicide? I have no statistics, but it seems to me that some suicidal people use the coronavirus to end their lives. Sometimes, I have heard from my depressed patients: "I would like to get a virus and die". Sure, we worked through such wishes. I worry that people with no psychotherapists can fulfil their death drives.

The group members also showed anxiety and suffering in June and July when the amount of sick and dead people reached its highest point. Trauma needs to be integrated, and that takes time. Psychoanalytic sessions give a space to speak.

Thinking and speaking about what, at times, feels unspeakable, the members of groups came to find a way to make it bearable. They blamed the pandemic, criticized politicians and mass media, the terrible state of our corrupted healthcare system, growth of poverty and domestic violence. They were glad that they were less vulnerable than others: elderly people, people at risk due to poverty and social conditions, with money not just for food and living but also for psychoanalysis. On the other hand, they felt sorry for those who do not have the resource for therapy during this pandemic.

Everyone experiences distress, despair, and anxiety at times, but those feelings sharply increased during the pandemic. For many, being stuck at home brought back feelings of an unhappy childhood. Some became more conflictual; for others, the social distancing became the desired state, while others found personal growth through many free online courses. I believe our quarantine made many people kinder and more caring for others. There is a hope that through psychoanalysis, we face the unknown future more confidently.

Since the start of the pandemic, we have offered free online assistance to medical staff in Kazakhstan. We offered a full schedule of webinars, consultations, supervisions for medical colleagues to support them at the unexpected pandemic affecting our world. It was evidence of our team’s kindness and creativity. Our team struggled with our own responses to the COVID-19 and lockdown. Nevertheless, we had enough resources to help people to find new ways of living and working. As if we were one step ahead in challenging the transformation of family and social life. The reality required our team of analysts to offer to our medical doctors free of charge individual consultations. I personally didn’t see them, but I have run free individual and group supervision for colleagues and students who saw the doctors and nurses.

The increasing flow of patients has challenged my supervisees. Many supervisees have not had personal analysis yet. Usually, in so-called peaceful years, a regular supervision group of mine consisted of 8 -10 supervisees. Now there are 30 people. Once a month, I run free supervision where there are from 40 to 60 participants.

I taught my supervisees to provide as secure holding and containment as they can. The theory of containment and holding, again and again, was recalled and applied in these crisis months. It became in a very high demand to contain and hold the experiences and feelings of patients traumatized by COVID-19.

When the pandemic reached its peak in July, we announced our readiness to see all the needy people for a very low price that was affordable for many poor and jobless people. We were confident psychoanalysis couldn’t be for free forever. Ones should pay for their inner work in order not to devaluate their own and the analysts’ work.

This pandemic showed that psychoanalytical knowledge and experience could be brought to the benefit of the local community through our psychoanalytic society. "As the president of IPA Virginia Ungarn said, “It’s a time to value and be proud of our profession.”

Anna Kudiyarova sees patient’s individually and in groups and is the Director of the Psychoanalytic Institute for Central Asia as the structural division of the NGO Psychoanalytic Association. Each year, the institute organizes 2 schools of psychoanalysis in Kazakhstan. Participants come from Central Asian countries.

Alongside her clinical practice, she leads social projects including; Clubhouse for Mentally Disturbed People and 2 Training cafés as workplaces to more than 30 employees with mental and behavioural disabilities.

Personally and professionally, she fights the stigma in Kazakhstan.

References

1. Kudiyarova, A. (2013). Psychoanalysis using Skype. In J. S. Scharff (Ed.), Technology and mental health. Psychoanalysis Online: Mental health, teletherapy, and training (p. 183–193). Karnac Books.

2. Hara Marano. Repairing the Toll of Uncertainty. https://www.psychologytoday.com/us/articles/202007/repairing-the-toll-uncertainty

Attachment 1

Instructions for online therapy sessions

1. Privacy. Security. You must arrange a separate room/space with closed windows and a door. No one should overhear you or read your notes during a session.

2. Silence and concentration. Leave children/ toddlers under the care of relatives/nannies. Warn all family members (especially jealous spouses and babysitters) not to disturb you for 1.5 hours.

3. Insurance. Spare network sources. In case of a power outage or sudden consumption of units, you should charge both your phone and computer in advance. It is desirable to use a computer, then you can see more, your hands are free, you can write in a chat if there would be some problem with voice. Your cell phone is needed for insurance, so you can quickly move from Wi-Fi to mobile communication. Put your cell phones on silent mode.

4. Prepare napkins (sneeze, cough).

5. Glass of water.

Attachment 2

Instructions for online therapeutic and supervision group members

Confidentiality of the material. Security. You must organize to yourself a separate room/space with its windows and a door closed. No one should overhear you or group members during a session.

Silence and concentration. Leave children/ toddlers under the care of relatives/nannies. Warn all family members (especially jealous spouses) not to disturb you for 2 academic hours. Put cell phones on silent mode.

Insurance. Spare network sources. In case of a power outage or sudden consumption of units, you should charge both your phone and computer in advance. It is desirable to use a computer, then you can see more.

Hands-free. A cell phone is needed for insurance, so you can quickly move from Wi-Fi to mobile communication.

Recording. Supervisees, be sure to prepare a keyboard, paper and pen. You will actively write answers to my questions and/or write down your thoughts for yourself to think about after a session.

Talk one by one. This means turning the microphone off all the time and turning it on only during your speech. Find the camera and microphone icons on your screen and learn how to operate them.

Prepare napkins (sneeze, cough).

Glass of water.

Attachment 3.

How quarantine influenced a patient of mine

The first session offline after the lockdown and summer vacation.

P: Hallo.

A: Hallo.

P: (lies down, a short pause) I would like to re-tell you what I thought during the quarantine on my life. It is like a report how did I analyze while you were absent. It is obvious like in many people’s lives, the quarantine made changes in my life and psychotherapy as well. My primary source of income is the job in the office as you know. Beginning from April we were transferred to remote work from home and the company had reduced our salaries by 50 per cent. Around this time, I moved to three personal sessions from four sessions per week as you recommended. Later, beginning from July I left only two sessions per week, because you increased the cost of sessions as you announced me some months before. You explained to me that you had been having another price for other patients for a long time as if you expected I would get angry. But I think it was quite fair and I accepted the rise of the cost without internal resistance. I heard once in your TV interview saying that the price of your sessions was a bit higher than I used to pay for 2-3 years. I think I even had a note of appreciation for you because for a long time I was allowed to pay old price despite regular inflation in our country.

I calmly accepted that I had to settle for two sessions because I had half of my salary and I couldn’t afford three sessions a week even if the increase in price was just slightly higher. Before as you remember well (laughs) I was impatient with the cutbacks of sessions but I have to admit that during quarantine it was amazing to me how calmly I accepted the new model of working with you. I think I was patient because the total number of my personal analysis sessions had reached 600 hours and it gave me a reason to be more patient. I said to myself: “Hey, at the end of the day it would be a shame to me if I overreact)))”.

Surprisingly for myself, I reacted to the salary cutbacks patiently while my colleagues displayed intolerance and even resigned from the job in that regard. I told you earlier it was very clear to me that due I did not have extra or passive income, I must hold on my job, whatever it is paid.

Nevertheless, this situation kept pushing me harder and harder to find additional skills and income. I believe thanks to psychoanalysis I already have my own ongoing dietary supplements selling projects. The quarantine and closure of stores in the cities has had a positive impact on my business because we adjusted to the online delivery of DS timely and made a good profit.

A: You are proud.

P: Sure. However, for now, I reallocate all investments in the second store and still do not withdraw my dividends. Therefore, the issue of other sources of income remains open.

As I know, we have discussed other sources of income at the sessions several times, but I preferred to stay “hungry” for sessions rather than to find new income. I think even this “hunger” had a positive moment because the value of the sessions opened to me differently. Before I used to lead a kind of idle life as a child and took the sessions for granted. Now, I feel the beginning of the time of consciousness. Please, don’t laugh at me. The reason why I think so is that after the quarantine in May, I finally managed to end my relationship with L. He is a man I had no future with. This breakup was the most painless one, despite I had only two sessions a week! Just online!! If anyone told me about it before, I probably wouldn’t have believed it. I cope!

A: You are proud.

P: Of course. And you know me. Even though I broke up with him after we lived together for 3.5 years, for whom I still feel gratitude and kind sentiments, I had no painful emotional outbursts even if I was in social isolation with you. (as if blamed me) While so many of my acquaintances and friends were breaking up, divorcing with scandal and mutual grievances, unable to withstand the quarantine.

In light of this, as I look back, I feel proud of myself, grateful to you, and to the man who invented the Internet. Yes, I want to dwell here on the topic of online sessions. Two or three years ago, I was very hard to agree to an online session and was constantly resentful of having to work online when you went going to another city or vacation. This time, instead of indignation, it was a humble acceptance of circumstances and even joy. Of course, in my observation, I have noted an increase in my internal flexibility. I was for a moment sorry and my past «hysterics» against online work seemed to be ridiculous.

A: As if you grow up.

P: Yeah. In general, I think I can firmly state that the quarantine has had a positive effect on my life, therapy and work. Despite the temporary, hopefully, financial difficulties and the reduction in the number of sessions, I had plenty of time to find new hobbies and interests while being on lockdown. I suddenly started thinking about financial literacy, and I discovered a lot of useful insights into finance. I was able to complete an online financial literacy course and it was a surprise to me that I already knew most fundamental things from working with you, from psychoanalysis. I passed all practical course tasks with ease and I was once again convinced of my leadership abilities. … (short pause)

The quarantine helped me to love classical music... with your help, of course. How? I watched your interview on YouTube. I became obsessed with ancient parables and wisdom following one of your posts on Instagram. Unfortunately, my special habit from an early age is that I used to walk around the house or down the street, or do any work with background music in my headphones. At one point, it made me nervous that I was listening to cheap pop or useless podcasts. But now I’m happy that even though I still have the habit of wearing headphones, at least I’m listening to useful things.

A: Or things that show we are like-minded...

P: …. Maybe. I go on with my report. When a lot of people were gaining weight being on quarantine, I was finally able to find a diet acceptable to me and get my body in order. And finally, thanks to the widespread online mode, I’ve resumed my Social Media Marketing training and I’ve already written up a business plan to launch extra income through SMM.

Now when our salaries have been restored, when I have more or less plans to improve my finances, I plan to resume three or even four personal sessions a week, and, certainly, not to stop my therapy for at least another year or more. Please, do not object me, I would not listen to you, sure, I remember your instruction that I must have deposit for one year to survive if the pandemic would last long time. Thanks to my working with you, I have learned to see the white eye by the black fish. (Ыhe means the Eastern famous black and white yin and yang fish)

I am happy to realize, the quarantine helped me to make crucial decisions and finally to move from words to actions. Hence, psychoanalysis helped me to get through the quarantine with ease and benefit.

A: Time is over.

P: Good-bye.

Attachment 4

Instructions for working offline

Please come out of the house wearing a mask and gloves. Open the gate and doors with gloves. In our psychoanalysis centre, wash your hands thoroughly in the toilet before entering your analyst's consulting room.

If you have drunk water/tea/coffee, leave the used cup on the edge of the table.

After leaving the analyst's office, put on your mask and gloves again.

Take care of yourself and others!