Therapists and Patients at the Epicentre of a Pandemic of Not Knowing

“Well”, I said to my colleagues gathered in little headshots about the Zoom Screen. “Well, there is a lot we don’t know. There is in fact a mass neurosis of not knowing. But, not knowing is meant to be what we’re especially good at. Isn’t it?” And all our little heads smiled ruefully and agreed.

It is 28 March 2020. We are meeting in our Zoom room, because all of us have had to leave our new clinical consulting space in Central London and lock ourselves down in our homes because of the Coronavirus pandemic. One of our number has returned to her home country, whose outbreak is elemental. A recent loss of a family member (not related to the virus) means that she has not joined us today. We have all continued to see our patients from home, using what technology has made possible; video apps like Zoom, VSee and Skype; the telephone. The technology is not new to us.

Not Knowing

What is new to us is that our practices are now wholly on-line, until we know not when. And the “not knowing” is a pandemic, socially as well as individually. Therapeutic professionals are at the epicentre of the pandemic of “not knowing”, a keystone of the art of psychodynamic therapy and now an essential life skill in the wider world outside the consulting room.

But what is it, this not knowing? Why are we psychotherapists and psychoanalysts supposed to be “good at not knowing?” From the time “psychoanalysis was born, with all its paradoxical conditions,…[there existed] the need for the analyst to remain silent and to interpret [while also] not knowing: it is the patient who knows”. (Boeker, 2018) [emphasis mine] The final paradox in the consulting room is that the patient may not know that she knows, and so there are two people who begin an engagement without knowing.

In August of 2019, I found myself enchanted by a book by Elizabeth A. Lambourn, Abraham’s Luggage; a Social Life of Things in the Medieval Indian Ocean World . It seems astonishing that in a history of a luggage list I found a treasure trove of inspiration for clinical writing. The book is a result of contemporary interdisciplinary research, that I think of as a “bio-psycho-social” paradigm for researching and learning about a time, a space and a person. Beginning with the material object, a luggage list written in 1132 CE, on the back of another piece of business correspondence, and, in fact literally between the lines, the book is a careful report of reflections upon and interrogations of the list. Lambourn does not hesitate to ask others about their observations and carefully, respectfully she allows what she learns from them to shape her own narrative. From her own background as a “historian of material culture and a cultural historian” she “has endeavoured to become …a ‘tiers instruit’ -literally an ‘educated outsider’ synthesising knowledge across domains”.

From 21 lines emerges the embodiment of a lived life in all its complexity. Looking at it through Lambourn’s eyes is like seeing stones shifting and changing colour in a tidal pool. The day passes; the light changes; the stones present different aspects of themselves. We see a businessman; his childhood; the social upheavals that disturbed him and his family; that family itself with whom he remained in touch no matter how far he wandered; his beliefs and adaptations to new ways; what he ate and why. I am reminded of the archaeological Freud. I am reminded of the explorations of the patient and therapist in the consulting room. And throughout the work it is clear that Lambourn is not only comfortable with not knowing, but is in fact stimulated by it, because it enhances what she does know. The ‘tiers instruit’, even has a savour of the therapist.

If I were to try to express the essence of my clinical self, on the model of Lambourn’s description of her approach to research and writing, it might look like this:

By education a humanist, and by training a psychodynamic psychotherapist, I seek ways of understanding and giving voice to the lives of people, as they live them from within themselves and as they live them among others and in the wider world. I try to facilitate a synthesis of my patients’ inner lives, with their lives enacted in the outer world. Things go wrong when the synthesis is damaged, misunderstood, cannot occur or has become a source of pain.

Patients and therapists – the tidal pool of the safe space

The relationship between patient and therapist begins, in the formal world of psychodynamic training, in a consulting room, often metaphorically called a frame or a container. The room is a true psychoanalytic object, the place where it is safe to approach what we do not know. The artist “Alberti …when he drew…first set out a rectangle, which he imagined ‘to be an open window’ through which he saw what he wanted to paint” (Hockney & Gayford, 2016). Some have described Freud's great achievement as “a technique which opened a window to enable observation to be made of the interior of the human mind.” (Hill, 1993)

The therapist cannot be said to know what it is to live life in the patient’s inner world, because it is the patient’s world, not the therapist’s. But the therapist can listen and give watchful attention to the many ways that the inner world is expressed. The therapist can bring the formality of her own training and theoretical models into play (what she does know), to help the patient hear first slowly and then ever more deeply their own voice; envision what has been hidden; feel their own sense of self. Rather like our beachcomber, the therapist works by reflecting upon the many-coloured pebbles of “emotional meaning and emotional communication” (Bucci, 2010) in the subtly changing pool of the patient’s conscious and unconscious thoughts and processes.

Psychodynamic practitioners practice a model often described as the talking cure, although I prefer to think of it as the listening cure. And to be sure, from its Freudian beginnings, there is an implicit “valuing of language over non-verbal forms.” (Bucci, 2010). Yet, findings in cognitive psychology and neuroscience today add to our understanding of the possibilities for communication from and with the unconscious worlds of our patients. Bucci points to a “world of complex thought that is non-verbal and even non-symbolic that occurs in its own systematic and organised format...; that is rooted in our bodies and sensory systems and that can be consciously known and comprehended, but that is not directly representable in words.”

Together therapist and patient begin to find words, symbols and images that come together to fill the analytic field in the space between them, to begin to transform what had not been known, into something known, and shared. (Ferro, 2006).

Winnicott speaks of potential space, “a psychological space between reality and fantasy that is maintained throughout one's life. It is the space in which playing occurs; it is the space in which we are creative in the most ordinary sense of the word; it is the space in which we experience ourselves as alive and as the authors of our bodily sensations, thoughts, feelings, and perceptions. In the absence of the capacity to generate potential space, one relies on defensive substitutes for the experience of being alive (e.g., the development of a ‘false self’ " (Winnicott, 1960) cited in (Ogden, 1988).

Creating that space is the most powerful outcome of the work between patient and therapist, because experiencing oneself as being alive is the most powerful personal environment for a human, providing the possibility for change. Getting there is not a trivial process.

The Epicentre – above the psychic explosions

The seismological definition of an epicentre is the point on the Earth’s surface immediately above a subterranean explosion. Brett Kahr uses the telling description of “vitriolic verbal assaults of our more vulnerable and volcanic patients [my emphasis].” (Kahr, 2015) The idealised safe place can be experienced as dangerous. Psychoanalytic work may be a great threat to a deeply repressed fear.

Before even having to come to terms with epicentres of disease, therapist and patient might often have found themselves contained over an epicentre of psychic fear and hate, facing each other.

The foundational psychoanalytical understanding of the unconscious begins with Freud’s observation in his earliest hysterical patients that unbearable experiences cannot be allowed to be conscious, and therefore must be repressed. “The ideas, phantasies and emotions of the dynamic unconscious revolve around earlier wishes and their later derivatives which have been removed from the conscious and ‘repressed’.” (Boeker, 2018) Also lying in the unconscious is repressed memory. The artist David Hockney remarks, “we see with memory, so if I know someone well, I see them differently from the way I might if I’d just met them. And my memory is different from yours; even if we are both standing in the same place, we do not quite see the same thing. Other elements are playing a part.” (Hockney & Gayford, 2016) Such is the relationship between therapist, the patient and each other’s unconscious processes. Only if they can find a place where each can believe in the possibility of attachment to the other and in a shared desire to keep the possibility of growth alive, in spite of not knowing exactly what the other sees, will the work succeed.

The conscious invokes fierce censorship over the repressed contents of the unconscious. (Boeker, 2018) So our patients have an equally fierce struggle to know what has been hidden away. Not allowing these fearsome events, wishes, or emotions to see the light of day, in effect defending against internal conflict, is a psychic gain. Thomas Ogden speaks of a “ form of experience … in which the individual is sufficiently capable of generating a space in which … he is capable of knowing that he does not know; he never entirely frees himself of this terror, much as he unconsciously attempts to lure himself and the analyst into mistaking his systematic misrecognitions for genuine self-experience” (Ogden, 1988).

But there comes a point when the psychic cost of the defence outweighs the gain. That is how people may find themselves in the consulting room, both in the sense of coming through the door in the first place and of uncovering a self, sleeping and unknown below layers of “misrecognition”.

Even in the most containing of times, then, our work may find us poised over potential explosion. What then can it mean if the carefully created and contained physical spaces are themselves to all appearances blown away by the state of the world around them; the tidal pool dispersed to the winds, the coloured stones fractured and submerged in other tides? When the causes and outcomes for the drastic transformation are unclear, novel indeed, and for most of us invisible “Not Knowing” takes on further meaning. This meaning does not encompass a useful “not knowing”, a benign therapeutic frame of mind or a defence against internal terrors. It seems to block out a sense of agency, potential action, casting shadows upon safe spaces. Has Alberti’s frame become a prison, not permitting the emergence of potential space?

Epidemic to Pandemic – the metamorphosis of the safe space and learning with the patient.

Epidemic and pandemic have since ancient times referred to disease. At their root is the demos – the collectivity of ordinary people (Kelly, 2011). What does it mean to be a member of the demos living in a pandemic? In one sense it means finding oneself as far away from a safe place as it is possible to be. It means being in a place where disease has spilled out of contained spaces into wider and wider spaces or populations. (Kelly, 2011) Pandemic is a word much bandied about as we follow the Covid-19 virus around the world, and in and out of hospitals, care homes, schools, sports stadiums, festivals, aircraft; all the places where people have been congregating so feverishly in the 21st Century. In most countries, some form of restriction and distancing has locked people away from the world, and other humans. Even as populations slowly return to public spaces, and exposure to other people, we do not know what might be the consequences of what was once normal social contact, at work, among families, friends and figures of trust, like teachers or hairdressers, or therapists.

Never has it been so clear in our work that therapist and patient are sharing the trauma of reality in the world that once contained the safe spaces. “We don’t know what’s going to happen next,” said a patient in early March. “Even you, with all your wisdom, don’t know.” I’ve always been aware of an undercurrent of irony from this patient. But on this day it seemed more a barely repressed anxiety of their own. Many of us have experienced a patient who has dismissed careful explorations of room changes with a variation on the phrase, “But you’re here.” One might wonder how safe and containing our presence still seems when it is evident that we are not immune to the shared trauma.

How present are we in the sometimes-improvised virtual spaces that we implemented from one day to the next? In fact, for the patient, their side of the “room” is wholly improvised. We have in our small practise in London, all of us been able to use technology over the past five or six years both telephone and video conferencing of one kind or another so neither we nor our patients are novices in the use of technology. However, we have always had more time in the interactive personal space of the consulting room. The consulting room has now become a virtual space and within the frame of our computer screens it is hard to know, yet, how much of the embodied non-verbal communication Is lost between the patient and the therapist. Consciously or not, we are relying upon what Dr Aaron Balick, in a webinar on 8th June (Balick, 2020), referred to as the power of residual trust. Our face to face sessions built up for many patients the trust that allows the work to go forward, even where we are not bodily present. How long can we or must we sustain this? And how do we create a similar trust for patients whom we first meet through the mediation of the screen?

Transition – learning with the patient

That safe space has now become virtual for the foreseeable future. Even if we can offer a safe enough passage to our rooms, we are still in confined space when we work, so in order to comply with public health guidelines, we will need to wear masks. At least in the virtual space, our faces are open. Indeed, through one patient, I am learning that the collaboration of patient and therapist in building the analytic field continues to be powerfully creative. Our patients have things to teach us in this space. They are inventive in improvising their own therapeutic spaces. One patient decided that it would be closer to a therapeutic encounter if our session was projected on his large television screen. Among other things it gave the therapist a fully embodied view of the patient which is unusual if we are using simply our computer cameras. More importantly, it gave the patient greater access to the therapist. And on reflection, I think it would suggest to me that I should invest in a better camera myself ( I also reflect that on the first day that we worked this way I had enormous difficulty in repressing the desire to say “I'm ready for my close up Mr DeMille” ). ¹

Just as we must acknowledge the greater context of the pandemic in which we all reside we also need to acknowledge the technology that is mediating our relationship and the loss of the fullness of non-verbal embodied communication I find that talking about this with my patients is very fruitful when the call drops when we miss parts of sentence is when the picture is fuzzy and unclear it is helpful to point it out not only does this clarify the communication it distinguishes the situation from what we shared in the consulting room to what we are sharing while depending on technology now there is a loss and a difference which cannot be ignored” (Russell, 2020)

There is another thing we may wish to acknowledge. In the transition from the safe space of the consulting room as we knew it, to the different safe space of the technologically mediated room, there is something that we may need to understand about our perception, that is the therapist's perception, of the safe space. We perceive it in the space itself. From our chair, we see the patient and we see the furnishings of the safe space behind that patient and we may imagine that that is what the safe space looks like to the patient. But of course, that isn't so. The patient sits in a chair and looks at us and what is behind us, just as they do now in the virtual space. So one of the things that has changed is our view. And we are no longer in control of that view. The patient is in control of that view. In some respects, they may also be in control of the view of us. This can become a powerful potential space. But as in Russell’s view that it is important for us to acknowledge the technology that is mediating our relationship with the patient, we may need to find some way of acknowledging the change of our understanding of space. It too needs to find its way into the dialogue. And, perhaps more importantly, we need to understand that we are no longer the owners of the whole space, if we ever were. This is something for us to think about.

A colleague also remarked to me that we cannot see what is on our client’s screen and therefore cannot know how they may have been using what is potentially the safe consulting space, for instance, to view pornography. It may need to be a new convention that we ask that all programmes and notifications be shut down for the 50-minute session. Indeed, I have had to learn to do this myself because the reliability and accessibility of the network is affected by the number of programmes I may have opened on my desktop. And perhaps we might allow a 60 minute hour, so that we can allow 5 minutes at the beginning of a session to decompress before entering the work and 5 minutes at the end. Many patients have reflected that they miss the travel to the session and the travel away, both times that allow them to prepare for seeing us, and for re-entering the world outside.

The screen which now contains us is a literal frame. I reflected above that in circumstances of traumatic change, the frame can seem like a prison- restricting what we can see or act upon. Can we find our way back to the fluidity of the tidal pool of our safe space? Another artist, Pierre Bonnard, often worked from memory, in colour straight to the painted surface. His windows are liminal, not constraining, often leading the eye to a peripheral glimpse of something else; a figure, a shadow in a mirror or in the glass, something on the edge of vision. (Schwabsky, 2019) I have experienced just such moments of intense connection and insight, even in this changed environment.

The patient who created a consulting room from his own space, and his memory of what mattered to him in our shared consulting room has also found respect for his own person which, while it was painfully emerging in the face to face work, was enabled by his embodiment in his own space. It has been a joyful growth. The lockdown may have its role to play, but our joint use of the virtual space also allowed completion of the psychic narrative that had not occurred outside. As in a Bonnard painting, I believe we both have an opportunity to respond to images refracted in the shadows. For the patient, it is possible that the messages that could not be explicitly stated face to face can find their way to the surface in this other environment. As psychodynamically trained therapists we may have a reluctance to relinquish the theoretical belief in the necessity of painful confrontations with the resistance in the room. However, our first responsibility is to whether we can create therapeutic relationships, in whatever conditions the real world provides. And if this can occur in virtual space, let us accept it, and learn how to work with it. (Bucci, 2010)

Adam, another patient had an even more overwhelming epiphany. He came first to the consulting room because of the destabilising consequences of losing a job in a company famous for its aerospace technology. It had not been, despite the glamour, a happy experience for him. He found himself being expected to compromise his sense of standards, and unable to communicate his sense of the dangers that resulted. In the end, he and others were made redundant. He struggled to find words for the overwhelming sense of unfairness, and of humiliation that his integrity was not recognised or valued. And for a long time, most sessions would be the scene of an internal combat which seemed to be between two powerful archetypal parental players in his internal landscape, determined not to release him, or rather determined to shout over his own voice. So that every effort of his to move onto a life that served his needs demanded a superhuman effort to make himself heard, to himself first of all before he could move even the smallest distance to individuation.

The great breakthrough came not in the face to face, but in telephone sessions when the full impact of a lifetime of being wordless and unheard not just at home but at school, unrewarded in spite of all his efforts to accomplish what was asked of him – which in fact he delivered upon. It was in lockdown and in a technologically mediated space that he released a climactic narrative freeing a voice and some knowledge of himself.

Balick also reflected (Balick, 2020)on the possibility that the “virtual space” makes it easier for the patient to leave. Two patients, while not formally ending have indeed evanesced. One, I believe, felt the challenge of both the insult to their carefully- and successfully- constructed public face; and of the exposure to others that they had been coming to see me. The person who had created that world, felt at some level that they must not expose themselves as needing someone like me. It might have been an insurmountable hurdle to find the private space at home or in the office. The other patient also had plenty of challenges to their work and family caused by the huge economic onslaught of Covid-19. For these two, there is perhaps a common element of belief that they must demonstrate a unique personal power to be able to keep the world on the tracks they have laid out for it. I find myself thinking about them often while feeling not rebuffed, perhaps, but kept at a distance. It may be an unconscious message about making me feel a sense of assault on my own omnipotent sense of control and value, as they do.

Public Space – psychodynamic not knowing as a microcosm of not knowing in the world outside

And what of the trauma that is public and shared?

Isabel Russell, in an interview in the BJP remarked that “one of the traumatic aspects of the pandemic right now in the beginning of May when I speak with you is that we cannot clearly see the future in fact we are existing in the trauma right now without any advantage of hindsight or perspective and when we are in a trauma it is very difficult to think or project into the future we are collectively grieving there are so many losses; loss of connexion, loss of safety, loss of a future about which we are now uncertain” (Russell, 2020)

Even as we apparently emerge into “normal times”, we do not know what that entails. The early peaks of illness, hospitalisation, and death have subsided, but the virus is still there, infecting about 3000 of us daily in the UK, at the time of writing. (Coronavirus (COVID-19) in the UK: Cases)

It is not clear that we will evade a peak in the autumn. In any event, Sir David Spiegelhalter, Winton Professor of the Public Understanding of Risk at Cambridge, says we will probably have to come to terms with living with a long-term risk to manage. ² It is unlikely that the virus will go to zero.

Therefore, we will need to continue a modified relationship with our patients even if we return to the room with them. For example, if we are to comply with public health guidelines we have to recognise that we are working in a confined space, even if it has a window that may be opened and even if we can sit at the designated safe distance. It seems on the evidence of worldwide communities managing the virus that wearing a face mask in a confined space is the safest way to reduce transmission of the infection. Therefore, we will need to choose which is the most complicated aspect of the face to face work; will it be speaking from behind a mask which conceals half our face and the face of the patient, or will it be speaking without the mask and leaving both of us, patient and therapist, at greater risk? Oddly, in the virtual space, our faces are open.

We all know that there is not a simple answer to this question and many more implied by Russell above. We know that many of the agencies that are meant to provide clear direction do not know the answers either. We also have been witnesses to a confusion of messages and a lingering sense that the safety of the population must be negotiated in the context of the need for recovering an economic engine of some kind, and for creating a safe way to educate our children, without whom there is no safe future. A public version of the residual trust we built up with our patients which has allowed us to continue to work therapeutically with them through dramatic change has not been sustained in the public space. (Reuters Institute for the Study of Journalism, 2020) (Fancourt, Bu, Wan Mak, & Steptoe, 2020). In England, levels of trust have dropped to about 35% for information received from the government, with devolved governments running between 45% and 50%. (Reuters Institute for the Study of Journalism, 2020)

Sharing the power of not knowing; an essential life skill outside of the consulting room

As we shift in our seats above the epicentre, we therapists will need to accept “not knowing” as a dynamic communication with our patients, not just an arcane phrase to describe a principle of practice. We will also need to acknowledge it as an essential reality in the here and now, outside the consulting space. We may feel vulnerable exposing to them that we do not know, in a real sense. But when did we ever have omnipotent knowledge in a real sense? Surely if that existed it existed in the transference, and we ought never to have allowed it to go unexplored and unchallenged.

However, what we do know is that “not knowing” is the essence of being able to feel the truth of another person’s narrative, whether expressed in stumbling words, in absence from our spaces or in creative adaptations to the therapeutic space. It is essential for the building of any relationship. It is important in our being able to learn from our patients, a powerful exchange in the potential space. It is, therefore, something that our patients can take away with them, to engage with the world outside; to help survive the tremors and explosions at the epicentre. It is part of the non-trivial work we do.

Having worked, as we do, so patiently and committedly, patient and therapist together, I have one final struggle. The final thing that I do not know is how I will be able over the coming months and years to bring my knowledge, and my care, for the humanity of each patient; my awareness of being able to work only one person at a time; my belief that if I, and my colleagues work with each of those people, we create, one person at a time, a better place for them, and for those around them; how I can bring all of that into the front line of a principled fight to retain the best of what we take out of this troubled time, and how we stand resolutely against the careless, thoughtless and narcissistic aspects of those who would have us again impoverish and ignore so many humans. And the thing I most don’t know is how I will be able to remember that the worst and most careless of us are human, too.

Anne Foster, MA, FPC (Fellow), UKCP (Member CPJA) is a psychodynamic psychotherapist in private practice in London and the Chilterns in Buckinghamshire. Her email is anne@annefosterpractice.com

Footnotes:

1 All case material is anonymised

2 Royal Society of Medicine Webinar - Behind the stats