Round Table: The reality of Covid and its possible consequences for the psychoanalytic technique
I was already suffering from the plague
long before knowing this city and this epidemic.
So many vertices, so many observations, so many levels of questioning, so many webinars on the theme of the Covid convey both the disorientation that has unmoored the needles of the compass guiding the analytical couple.... as well as the whole world, but also express the fact that we are still fully subjected to the shock of the events and cannot yet benefit from a highsight , of the pandemic storm. In a frantic quest to find meaning and avoid chaos, we multiply our approaches and comments while ignoring even today what will be the outcome, the duration, the consequences and the aftermath of this plague.
At a global, social, family, economic, scientific and epidemiological level, we are flooded by a stream of remarks in all directions, or even by fake news, with nonsense about this virus. Doubt, relative powerlessness, death in our sights, indecently brought to the fore from the shelter in which we usually keep it repressed, all these emotions strike us with full force and trigger to neutralize angst, depression and fear , a set of defenses like denial, splitting, manic responses, phobias... all these tools our psyche has at its disposal to confront chaos. No one remains untouched, not even psychoanalysts.
The reality of the health crisis devastated us because we were unprepared. But the lightning did not appear suddenly in a blue sky. It was already full of dark clouds, and multiple crises were shaking the meta -frames (Kaës) of our social benchmarks; the environmental crisis, the endangered democracy, the migration disaster, threatened species, and the collapsing economy have already weakened our guiding beacons.
Therefore, with this round table in mind, I started thinking about the approaches and techniques that could be useful in these overwhelming circumstances and I decided to target and identify, a few tools and directions from my own clinical practice, that appeared to be relatively stable landmarks or survival buoys and helped me navigate these stormy waters and avoid shipwreck.
The inner frame / the outer frame
Mr. B is in analysis, his tight obsessive defenses have long countered his positive transferential movements. When the first lock-down was ordered in Belgium, he had just recently started feeling more comfortable with me. In a dream he was seeing a client in the office of his former therapist (who had helped him a lot but who, unfortunately, had later on agreed to visit the patient in his home. There had not been an intimate relationship, but all the same!). In his dream, B had fallen asleep and his client had left. In his associations, he recalled the seductive behavior of his mother when he was a child. The next day was the last session before the vacation, which coincided with the government’s decision of “lockdown”. As with my other patients, I offered to see him remotely via telephone or Skype if the confinement would still be in place after the holidays. This seemed impossible for him because both his wife and son were at home. He told me: “And so you would come just like that in my house? I would feel that as something incestuous!” He added “Also, what matters here is not what is said, it is what happens, it is the emotional. For me it is important to get out of my house, to come to your house, there's the symbol and all that.”
Obviously, entering his home via phone or skype risked repeating the incestuous intrusion by his previous therapist which had reactivated the traumatic experience of his mother’s seductive behaviors he had been exposed to earlier in his life.
A month later, after the end of the lockdown, Mr. B came to his session wearing a mask, even a face shield and was washing his hands repetitively with antiseptic gel. Then, after telling me that it was easier for him to speak from behind a mask and therefore a little hidden, he stated firmly that he was not going to continue the analysis because the situation seemed too dangerous. His decision sounded clear: even with through mask the virus can pass, there is no such thing as zero risk. He did not want to be contaminated nor contaminate his family. His hostility towards me was evident but it was a question of reality, he insisted. “Even with a Plexiglas between us it would be too dangerous!”
I was very uncomfortable and didn't know at which level to answer. It was the first day post lockdown with all my patients: masks and gel made their way into my office; my switching from face-to-face sessions to skype or telephone sessions was also shaking my therapeutic frame. The fear of viral transmission, from one patient to another or from or to me was obviously present and interfering with the quality of my listening. While I was silent, focusing on some internal reference points, I recalled the atmosphere of the last sessions. I could then intervene and show him how much his negative reaction and the threat of interruption was allowing him to distance himself from the “letting go” that had begun during the last sessions, and that were likely to worry him, especially if the therapeutic frame was no longer held. This interpretation restored calmness in my patient but, above all, it allowed the thread of the intrapsychic processes to be picked up again. What followed went well after that.
Discussion: the dangerousness of the external Reality was covering up Mr. B's internal dangerousness, which was now even more or at least as much at risk to bring him on shaky grounds.
The unconscious intermingling of the Realities could have precipitated a shipwreck for lack of adequate anchoring, and the patient's unconscious resistance had drawn on the source of the external trauma. My own external frame was also cracked by Reality (gel, masks...) and by the ambient fear. It took me some time to find the thread of the analytical process again.
According to Green, it is necessary that "the analyst has previously internalized the therapeutic frame, so that it can remain always present, even if it cannot be applied; it will act as a point of reference...". The analyst's internal framework, inheritor of her personal analysis and all her commitments to the analytical process, is therefore one of the best guarantees for the continuation of the process when the benchmarks waver. But far from being watertight, a certain porosity between the external and internal frameworks creates a dynamic and a flow between the two, that depends on events that animate or disturb them, including the analyst, as we have just seen. We should also mention the temporary disturbance in the free floating attention of the analyst when a patient reveals that one of his relatives has been infected by the virus or simply when he sneezes. Let's add to the complexity by saying that it was also important to see how much Mr. B's anger towards the external Reality conveyed a real anxiety about his health, but also a displacement of his anger towards me. A subtle combination of empathy and listening to his internal reality were as such required to grasp the entirety of his psychic movements. For even Plexiglas would not have been enough to prevent the deleterious effects of his death drive in this situation. Thanatos was as restless in the depths of Mr. B.'s darkened soul as the virus was in the atmosphere.
The screen that separates and unites
The compass goes wild again when it comes to resorting to the use of the screen to continue our therapeutic work. Unthinkable for some patients, it will turn out to be inhibiting for some, and enabling for others. For some, the screen has allowed the continuity of the treatment; it is undeniable that the phase of the treatment, the initial setting, the psychic functioning of the patient are determining variables to be taken into consideration when thinking about the impact of the screen on the analytic process. The screen or the telephone have also made it possible to offer decisive and life-saving analytical sessions for people in distress during this epidemic. The remarkable works by Anna Maria Niccolo and by Mariza Vejmar, those carried out in Portugal, and also some in Belgium can testify to this.
But I will limit myself today to discussing the temporary use of the screen during lockdown for analysts or patients in analytical therapy.
Examples: 1/ Madame X, a very high functioning professional woman, whose operative functioning surprised me. After a period in which she didn’t report any dreams, she talked to me during a Face Time session about her Crohn's disease and her belly, which was on the verge of bursting ever since the death of her father. The next time, she spoke, in no particular order, of her childhood fears, emotions that were as always expressed through her body, also about diarrhea, then about a nightmare of a mouse, she is phobic of mice, and which runs very fast on a sidewalk. She evoked afterwards the climate of terror that reigned in her family when, at a time when she was very small, she heard her drunk and violent father come home. She was then ready to leave and run away ( maybe like a little mouse?- Her general appearance as well as her face often reminded me of a little mouse). Even today, she feels that she still carries the fears of a 6-year-old girl in her adult body. With me too, she feels child-like expectations for security. She thinks that her intellectualising must surely have been a protective envelope from all this. But as a very little girl, before she was of school age, she cannot remember how she has responded. “Maybe with your body”, I said, “by evacuating to make the fear go away”. Obviously, the connection was made as she answered, moved and quite uncomfortable, how every morning she still has to “evacuate
before starting off to work; it is imperative and everything is evacuated in 30 seconds. Often she doesn't go out because of fear of being surprised by her need to go to the bathroom. This is also why she doesn't spend any vacation with friends. She hates it when people see her going in or out of the bathroom. Could someone hear her? At the following session, Mrs. X dreamt of a tiny little grey mouse round as a toy, she opened the door for her and the mouse slowly left. Relieved by the mouse's departure and by these recent sessions, Mrs. X did spontaneously shared that she had told me these extremely important things about her body and that she would never, ever, have been able to express it in front of me. She would have been too ashamed. It was easier from her home because she was feeling more secure, she was in her own room, with her things and she did not have to park to come to my house; she added; “I'm small but here it doesn't bother me, whereas at your house, you have “all your space” (gestures to support this). “I think that the mouse is gone because I could identify my current fears with the fear of my father and everything that is still linked to it... so that's it, the mouse can go”.
For sure, these sessions were surprising and liberating.
In a recent article, Martin Gauthier compared the screen to Perseus’s shield ( a reflective mirror-like shield). On the screen we can see the other person like a picture on a surface in 2 dimensions -(and not directly through the 3-dimensional vision of the eyes), which prevents the other from exerting any Medusa-like action on his interlocutor. We know how much Medusa, well described by Pasche in its archaic version , can fascinate and petrify the one who looks at her to the point of annihilating him. If Perseus was able to defeat Medusa, it is because Medusa’s gaze reflected on the shield and no longer looked at persee. Was it this that had prevented Mrs. X from being able to exist as a little girl and open up in front of me in “my” home? Her failing system of para-excitation and her emerging subjectivity put her too much at the mercy of my magnified and mesmerizing gaze (“a la Medusa”) When I was reduced to a mere surface on her computer screen, she could let out these childlike words and a never-expressed sense of shame. It remains to be seen whether the most important thing could be to be in front of me without being frozen by my gaze. Could one also think that these sessions took place in somewhere else, in an in-between virtual space, in a virtual encounter almost like a rehearsal before the real meeting at my home?
2/ Mr Y, protected by the distance, was able to express his desire to wring my neck. Unable to talk to me about his violent feelings in a face to face contact, also sheltered from acting out, he could enact his anger in words in an action which will have to be taken up again in person after the lockdown.
3/ During the lockdown, another patient in analysis was able to dream of a guardrail (which could symbolize the continuity of the analytical process) on which she could lean on to advance further in the discovery of her infantile sexuality conflicts. In these three situations, the screen could either put a comfortable distance between the patient and me (example one and two), or bring the third patient closer to me, as she was looking at our skype sessions as a railing on which she could lean. Perseus' shield in the first two patients, a symbolizing tool in the third one.
It seems impossible to me to generalize the effect of the screen in these situations. They need to be examined and thought through individually each time. On the other hand, the metaphor of Medusa and Perseus’s shield may be helpful to understand many situations.
We can develop our ways of registration and combine our observations to improve research. For example, the original conceptualization of the framework by José Bleger in 1967 can improve our orientation and understanding of the effects of the work by screen. Bleger clearly showed that it was the symbiotic part, the most archaic part of the personality, that was deposited onto the therapeutic frame, and that the frame remained silent as long as it did not fail. There is no doubt that a neurotic patient can project on this frame parts of himself that are different from those of a psychotic patient. Also the analyst deposits certain archaic parts on his or her usual frame of reference. My patient in analysis, who evolved more on the side of neurosis, was able to preserve the symbolic function of the process and to rely on an analytical railing to continue her exploration of her infantile sexuality. Mr. Y, protected by the digital shield of Perseus, was able to act through words the violence of an upsetting experience in this extraordinary situation. Thus, it seems important to be able to qualify the patients' reactions according to what each of them had previously projected on the external frame and on the metaframes that had just been shaken.
Death is here, conspicuous. It is in the air, in the sound of ambulance sirens, in the daily death count, the lockdowns, the silenced cars, and in the almost insolent bird songs that we can hear again. Death is here! We have to fight and to survive!
Nothing is new, really, if we look at the statistics for traffic accidents or cardiovascular events. What is new is this brutal exposure to a global reality that makes us suddenly aware of our vulnerability, that makes us lose our sense of direction, and that can exceed “the linking capacities of our selves”! The urgency to fight for life is obvious; we are at war. The danger seems to come from an external reality, a “Chinese virus,” said Donald Trump, not afraid of inaccurate, hateful, and racist projections. It is so much easier to invoke outside enemies than to use scientific artillery against this tiny virus that plunges us into powerlessness…. indeed, he did not succeed.
But where does this virus really resides? In the other, inside the other, the analytic patient but also the analyst, the “Nebenmensh”, therefore in himself, beyond external and bodily boundaries. Denial, projection, splitting, propelling danger and Evil “elsewhere”, or displace and partly focus the problem on governmental and scientific strategies. For those who accept the reality of the epidemic, endurance, a guarantee (necessity?) for survival, will be put to the test. Depression threatens. I heard a young doctor who was plunging into melancholic thoughts about the end of the world. His vitality and endurance had given way to the death drive that was pushing him towards nonexistence.
But the climate of death can also induce unusual reactions. Dominique Scarfone (2020) tells us that situations of great uncertainty can influence our choices and promote thoughts towards binary positions. Certainly, and I think that for reasons of survival, these situations can go as far as to induce a transitory “depsychization”, a continuous flattening of the psychic life, a topical crash of the preconscious as we can see in certain “operative functioning”. One could almost speak of “functional operative functioning”, a survival movement fed by the death drive, which Nathalie Zaltzman has illustrated so well with her conception of the “anarchist drive”. It is a time of narcissistic withdrawal, of bodily withdrawal, of minimal psychization, of monotonous feelings and moroseness, and of centering on the materiality of what is said in order to stay silently alive.
It seems important to me to think about this and to respect this adaptive break while waiting for the return of libido and life. When using phone sessions, certain exchanges became impoverished and were reduced to surgical accounts, testifying, it seems to me, to this economic withdrawal necessary for survival
Finally, I fully subscribe to the ideas of Julia Kristeva (2020) when she says that the pathogenic agent is, of course, within us, just as it is within human genetics. A Kulturarbeit to elaborate Evil within us becomes therefore necessary, and the challenge that we are all facing today could offer an opportunity to do just that. Still, the fact that we are not yet in the afterwardsness of the pandemic is depriving us of the possibility of deepening this Kulturarbeit in the “hic et nunc” which should be done in times to come.
And this allows me to end this presentation as I began, with another quote from Albert Camus: "...everyone carries it within himself, the plague, because no one, no, no one in the world is untouched by it ».
Bleger J., (1967), Symbiose et ambiguïté, trad franç Paris, PUF 1981 Psychanalyse du cadre psychanalytique in Crise, Rupture et Dépassement, Dunod, P. 255-285
Camus A., (1947), La Peste, Gallimard
Gauthier, M., (2020), La caverne de Théo. Dans quel espace vivons-nous aujourd’hui? Online publication: May 28, 2020 DOI https://doi.org/10.7202/1069698ar
Green A, (2000), Le cadre psychanalytique: son intériorisation chez l’analyste et son application dans la pratique, L’avenir d’une désillusion, PUF, p.42
Kristeva J., Scarfone D., (2020), La situation virale et ses résonances psychanalytiques. Conversation webinar de l’IPA, 14 juin 2020.
Pasche F. (1971), Le bouclier de Persée ou psychose et réalité, RFP, 35, 5-6 p. 859-870
Zaltzman N., (1979), La pulsion anarchiste in Psyché anarchiste Débattre avec Nathalie Zaltzman , Paris, PUF, 2011