Working online due to the COVID‐19 pandemic: a research and literature review

Abstract

Given the contemporary situation of many analysts in the world now being forced to work online due to the effects of the COVID‐19 pandemic, it is important to review the working online issue. Substantial debate over previous years has questioned whether a genuine analytic process can unfold through online work. This debate is reviewed with the conclusion that such a process is not necessarily precluded. Research outcomes are then reviewed to highlight those things that can facilitate positive outcomes when working online. These cover the ‘online disinhibition effect’, the therapeutic alliance, particular ways of using the screen, focussing on trauma, the importance of self‐awareness, knowing the predictors of mental health, certain potential positives of isolation/quarantine and psychotherapy interventions that may be currently needed. Final recommendations and suggestions are then presented as in the diagnosis issue, professional development and guidelines to do with practical and ethical considerations.

Introduction

Given the contemporary situation of many analysts in the world now being forced to work online (whether they like it or not) due to the COVID‐19 pandemic, it is of little surprise that Scharff (2020) recently said, ‘suddenly teleanalysis that has been avoided as unsafe [because of security concerns] is now recommended! Yet, for many analysts there has been no time to prepare’ (p. 585). It is important, therefore, to review the working online issue because the COVID‐19 pandemic and its effects could last longer than desired, so that online work may continue to expand.

Prior to the pandemic, online analysis was already occurring as in the China American Psychoanalytic Alliance (CAPA) which has overseen the training of psychoanalysts and psychodynamic psychotherapists in China by American psychoanalysts since 2005 and where initial interviews, entire training analyses and the supervisory processes have all been conducted on Skype only (see Fishkin et al. 2011; Scharff & Varvin 2014). Specifically within analytical psychology, one example of the trend toward expanding online work would be https://www.jungianonline.com which Jungian analysts have been using since 2011.

In terms of the general Psychoanalytic School, over previous years there has been an ongoing and extensive debate concerning working online, and recently Gutierrez (2017) notably concluded that ‘little agreement has been reached with respect to the essential elements in the analytic process that come into play in telephone teleanalysis’ (p. 1099). A summary of this ongoing debate has been previously covered in Merchant (2016). It is Scharff (2018) and Isaacs Russell (2015) who have primarily forged the divergent opinions to do with online work and they have both recently responded to the issue due to the COVID‐19 pandemic. Given the contemporary global situation, it is important to overview the responses within the Psychoanalytic School so as to determine what can facilitate positive outcomes when undertaking an analytic process online.

Responses to the COVID‐19 pandemic by the Psychoanalytic School

An up‐to‐date psychoanalytic response to the COVID‐19 pandemic is that of White (2020), who not only comments on the progressive effects on her of online work during the pandemic, but offers a good contemporary summary of many of the negative critiques of online analysis, which she concludes is a ‘temporary necessity’ only. In particular, White argues that avoidance of the negative transference can occur in online work, as well as a ‘distancing’ effect that can enable some patients to hide from their neediness. She maintains that such issues can lead to dangerous oversights by the analyst and that online work can thereby enhance resistance to the analytic process. As a flow‐on issue, White questions whether online work can inadvertently speed things up (due to the sense of a ‘safe distance’), thereby prompting a ‘leaping over the patient’s defences and breaking resistance that simply needs the time of analysis to work through’ (p. 581). She also describes other analysts’ experiences of working online, which many say is strenuous, no doubt due to the intense ‘listening’ being done to pick up relevant cues when not in‐person. As such, White believes ‘evenly suspended attention’ can be compromised whilst the ‘hit or hold’ option has also been removed from the process. Overall, however, White’s anecdotal opinions offer little that is new to the psychoanalytic critique of online work, which is why sound research on the issue is critical.

In responding to White (2020), and to argue that a genuine analytic process can occur online, Scharff (2020) reiterates Suler’s (2004) ‘online disinhibition effect’ by saying that online work can enable patients ‘freedom to access negative transference that they had not been able to express in the analyst’s office’ (p. 586). She goes on to assert further that online analysis can work if we reflect on the difference between it and in‐person sessions, including its impact on intimate connection and the various ways of expressing resistance. With respect to being reflective, it is noticeable that Trub and Magaldi (2017) after interviewing 26 psychoanalytic clinicians in relation to online work, concluded that practitioners can easily become unreflective about its clinical implications. It is markedly important, therefore, to consider these issues, hence this paper.

Scharff (2020) goes on to suggest two major adaptations for online work. First, to mourn together the loss of in‐person connection and second, that ‘the analyst needs to use technology as a third element in the treatment relationship’ (p. 587). In other words, for the analyst to use the patient’s projections onto the technology. Such an adaptation was originally advocated by Dettbarn (2013), who not only presents the case example of a patient experiencing a technology failure as ‘evidence’ of the analyst’s aggression, but critically describes how this negative transference was processed appropriately in the online work.

On the issue of transference, Roesler (2017) correctly says, ‘the point is not whether transference occurs or not in virtual interaction – it certainly does … The point is whether the whole therapeutic setting maximizes the conditions to make this transference conscious and to work it through’ (p. 388). Other case examples beyond Dettbarn (2013) certainly evidence that transference projections (both positive and negative) can be sufficiently enabled and suitably processed in an online analytic setting (see Bassen 2007; Merchant 2016).

Another contemporary psychoanalytic response to working online as a result of the COVID‐19 pandemic is that of Svenson (2020). In describing her online experience, she alludes to three critical components: first, a new level of trauma seen in patients as a result of the pandemic; second, her own processing of the difficulties and problems the pandemic has initiated personally; and last, having to adjust to a new and different way of working. Svenson concludes that the ‘medium magnifies the dynamics’ (p. 448), hence long dissociated painful experiences can get confronted. This experience again aligns with the ‘online disinhibition effect’ (as above) and calls into question White’s (2020) assertion that online work can have a ‘distancing’ effect that enables some patients to hide from their neediness. Similar to White, Svenson also describes how online work can lead to ‘a kind of exhaustion’ (p. 447).

Isaacs Russell’s (2020) response to the COVID‐19 pandemic provides a succinct overview of her less positive position regarding online analysis. She points out that ‘it is crucial to recognize the differences between embodied communication in a shared environment and mediated communication’ (p. 365), which is a view previously argued in depth in this Journal by Roesler (2017), in that no transfer of our in‐person techniques and methods can be made directly to online work.

Isaacs Russell (2020) also mentions a ‘loss of presence’ in online work, so that ‘the potential to “kiss or kick”’ (p. 367) is removed, prompting a view that ‘technology “works” … because we have an illusion of this sense of presence’ (p. 368). Furthermore, emerging from her involvement with the APSaA COVID‐19 Advisory Team, Isaacs Russell notes that ‘themes of loss, fear and grief [have] emerged’ for analysts, including the experience of actual deaths in addition to issues about ‘the loss of routine, environment, life as we have known it. We are all threatened with helplessness, loss, with death’ (p. 366), she concluded.

Another major issue Isaacs Russell (2020) discusses is the exhaustion many clinicians feel after working online (as above). She suggests this may be because we lose ‘many subtle non‐verbal cues [and that] we have to work so much harder to perceive the whole communication’ (p. 367), which can be compounded by an ‘anxiety of concentration’ so that we ‘narrow our focus and concentrate’ and are ‘hyper‐vigilant’ (p. 368). Overall, Isaacs Russell concludes that, for her, with online work ‘[t]here is little space for silence, solitude and recalibration’ (p. 367).

The issue of online exhaustion would appear to be a recurring theme in the literature. For instance, prior to the COVID‐19 pandemic, Gutierrez (2017) gathered analysts’ anecdotal experiences of working online and concluded that additional effort seems often required, and that ‘intense feelings of … tiredness during or following the online sessions’ (p. 98) can occur. Similarly, the sense of ‘working too hard’ when doing teleanalysis is also reported by Bassen (2007), for example, when referring to a Panel report by Jane Kite, she says she ‘feels she is working too hard to engage her patient in phone sessions, as if they are constantly in danger of losing the connection’ (p. 1037).

Furthermore, Isaacs Russell (2020) comments that practitioners have to navigate technology failures and boundary changes since quarantine means many now work from home, that is, in their own personal space. She argues that all of these factors can work against reverie, a view with which Trub and Magaldi (2017) concur, since some of their respondents comment about its loss through having to attend more intensely to the patient and not to themselves. Other issues their respondents commented upon that could interfere with reverie were self‐consciousness due to seeing one’s own image on screen, finding silences less comfortable, having anxieties about loss or interruption to the digital connection and being distracted by text or e‐mail notifications. Similarly, Isaacs Russell (2020) comments that when working online, analysts need to be aware of such distractions as email and texts.

These contemporary publications give a succinct and comprehensive overview of the debate across the Psychoanalytic School in relation to online work, and it is important for analysts to be aware of them and any potential difficulties/problems that can thereby arise. However, despite the debate and the issues it raises, it is important to realise there is sufficient evidence that a genuine analytic process can occur online. Given that the contemporary COVID‐19 pandemic is forcing many analysts in the world to work online, it is important to review that evidence, and then to see what can facilitate further positive outcomes.

A genuine analytic process can occur online

A summary of the ongoing debate concerning this issue up until 2015 has been previously covered in Merchant (2016), and from case material and other research at the time, it was possible to conclude that:

Physical proximity of the [analytic] participants is not necessary because there is a cross‐modal communication between the human senses (underpinned by audiovisual mirror neurons [Gallese 2003]), in addition to the instinct for communication and interpersonal understanding [Fonagy 2003]. All these can be activated [online]. Consequently, there is ample and accruing evidence that transference, unconscious communication, countertransference (even of a somatic nature) and synchronicities can occur.

(Merchant 2016, pp. 321‐22)

Overall, there was sufficient evidence that a genuine analytic process is not precluded by working online, especially when it comes to the crucial elements of transference and countertransference. A later and apt example of a positive transference unfolding in teleanalysis comes from Bassen (2007). When outlining contributions by participants at a 2005 APA Panel on the issue, she says:

To [Charles] Hanly’s surprise, the telephone facilitated the useful development of an erotic transference, in the absence of repeated visual contact’ [and that this] ‘phone analysis also led to a further working through of the paternal transference, resulting in deidealization … Hanly concluded that the essential processes of free association, transference, understanding, and instinctual maturation need not be compromised in telephone analysis. He feels that the basic interpretive, responsive, holding, and witnessing functions can be sustained by the analyst without a need for modifications.

(Bassen 2007, p. 1034)

In terms of the countertransference, across her four edited books, Scharff (2013, 2015, 2017, 2018) has provided many case examples, and the section on the ‘Countertransference’ in Merchant (2016) covers similar material. At that time, Carlino (2011) provided a succinct and excellent example when one of his patients telephoned him on the way to a session saying he felt dizzy and sweaty. Carlino says:

At that moment I felt a sudden shooting pain in my lower chest/upper stomach area, which went away very quickly. In an act of introspection I scrutinized myself and thought it could be a countertransference message that, due to projective identification, had an effect on my body. I instructed the patient … to go to a medical emergency room.

(Carlino 2011, p. 92)

The patient did so and was diagnosed that day with a chest angina and potential heart attack, the latter being averted due to the speed with which he was treated. And Carlino (2011) most aptly concludes:

In analytic dialogue carried out by telephone, the transference connection operates as such, allowing for the production of emotions or physical symptoms of a countertransference nature.

(ibid., p. 92)

This is a particularly pertinent example, because Carlino’s (2011) countertransference experience is of a somatic nature which runs counter to a frequent criticism within the Psychoanalytic School. For instance, Trub and Magaldi (2017) discuss one analyst who described their loss of somatic signals from the body during online work. Such differences are likely to be reflecting individual analyst’s capacities and proclivities, since Carlino’s experience of the somatic countertransference during online work indicates it is not necessarily precluded.

Within our own tradition, it needs to be kept in mind that Roesler (2017) has argued that essential non‐verbal elements in analytic work can get lost or distorted in online work. However, both the above and previous case examples in Merchant (2016) indicate this may not necessarily occur to the point where the analytic process is rendered not ‘good enough’. And this may be due to the non‐verbal ‘contextualisation cues’ Roesler outlines.

Overall, given the evidence that a genuine analytic process can occur online, a flow‐on and crucial issue is then to determine what can augment and facilitate positive outcomes when working this way. And this may need to be an ongoing focus of our attention because of long‐term consequences, for as Estes and Thompson (2020) put it in relation to the COVID‐19 pandemic, we could be in ‘a collective continuous traumatic stressor’ (p. S31).

Relevant research findings in response to the COVID‐19 pandemic

Awareness of the ‘online disinhibition effect’ (Suler 2004)

Suler’s (2004) ‘online disinhibition effect’, to which Scharff (2020) has alluded and which media psychology calls the ‘distance medium’ (see Roesler 2017), is important to keep in mind, for there is ample clinical evidence as to its utility in allowing both positive and negative material to come into the foreground, which can then be processed analytically. Indeed, it is noteworthy that even Gutierrez (2017), when commenting on the inherent split he sees in videoconferencing, does state that it can allow difficult material to be said, as in love or hate in the transference. So despite all of the criticism of online work he discusses, the ‘online disinhibition effect’ can be an extremely useful occurrence analytically. As an aside, it is also significant to note another positive conclusion Gutierrez draws in relation to the inherent split he sees in videoconferencing: he maintains that with sufficient attention and work, it is possible for the inherent split to be mitigated through mutual understanding by both parties, which can enable it to be overcome.

In early work to do with the issue of ‘disinhibition’, Scharff (2012) reported on three cases related to it. The first alludes to a case presented by Symington at the 2009 International Psychoanalytic Congress ‘whose analysand had to travel after years of in‐person psychoanalysis, [and] found that the dislocation of being away from home and having to connect to him on the telephone revealed a transference delusion previously not brought out in the consulting room’. She also describes that ‘Richards (2003) reported on an analysis by telephone in which a sexual perversion, hidden in person, emerged only in telephone sessions, and this recalled excited phone‐calls to the analysand's mother’ (p. 85). The third case is one of her own where ‘the use of the telephone allowed the analysand to reveal more vivid detail about sexual abuse than was possible in person and gave the body freedom to give full expression of fear and disgust’ (p. 89). And more recently from other modalities, Martin et al. (2020) from their extensive literature review have shown with some studies that with online work, ‘[p]articipants exhibited higher levels of imitation, spontaneity, trust and disinhibition, which inadvertently led them to communicate and interact more with the practitioner’ (p. 39). Clearly, these examples show that ‘disinhibition’ can be clinically very useful in bringing previously unacknowledged material into the foreground, and so is not in itself a negative phenomenon. It is more the case of the analyst being aware of the possibility. Further case examples are outlined in Merchant (2016).

In terms of certain patients, it is also noticeable that in Martin et al.’s (2020) review, they found research studies suggesting that those with shame and self‐consciousness, who need high levels of control and have avoidant coping styles (often seen with eating disorders and anxiety sufferers), frequently prefer online contact. It is definitely worth noting that patients with such symptoms are apt to respond more positively to working online, and that this need not preclude the longer time that White (2020) maintains analysis requires.

Concerning the ‘shame’ symptom in particular, it is noticeable that in Richards’ (2001) summary paper of a psychoanalytic symposium on telephone analysis, it was concluded that ‘[c]ase studies showed that telephone work was especially useful in uncovering patient need for emotional distance and patient shame about physical characteristics’ (p. 388). In one example, Sara Zarem ‘chose to use the telephone as an alternative to face‐to‐face treatment for therapeutic rather than logistical reasons’ (p. 390), since the ‘patient specifically wanted her therapist to recognize her voice, not her body. Her voice represented her fantasy self’ (p. 391). It was by using the telephone that Zarem gained the appropriate understanding. In other words, a ‘safe distance’ which aligns with the ‘online disinhibition effect’ can be used productively.

Promoting the therapeutic alliance

Research indicates there is no reason for the therapeutic alliance that analysts have developed with their patients to be jeopardised when the analytic process moves online. For instance, in response to the COVID‐19 pandemic and that clinicians are being required thereby to work online, Martin et al. (2020) reviewed 116 different virtual and digital (V&D) programmes across the domain of general psychotherapy and concentrated on 26 that showed ‘robust evidence’ (p. 21) as to their effectiveness. Their report is freely available online, and whilst they particularly focussed on children and young people, they found that digital interventions can be just as effective therapeutically in the short term compared to in‐person sessions, but that these ‘interventions are more likely to be effective if they incorporate communication with a practitioner’ (p. 28) and ‘in real time’ (p. 29). This adds credence to the positive psychotherapeutic potential of analytic online work, no doubt due to the personal contact that can be maintained via the medium. Aligned with this view would be Cipolotti et al.’s (2020) findings with UK neuroscience health care workers during the pandemic, who responded better to one‐to‐one interventions that were personally tailored. And it is personally tailored responses that individual analytic work can actually provide. All this accords with the value and importance of the therapeutic relationship, which online work does not necessarily preclude; for example, Martin et al.’s review highlights research evidence that a positive therapeutic relationship can occur online, just as Bickmore et al. (2005) and Pihlaja et al. (2018) had previously found. A related finding has been made within the Psychodynamic School, as Gordon and Lan (2017) found that the positive effectiveness of trainees’ own psychotherapy when conducted online, depended far more on the empathic quality of the therapeutic alliance than on proximity. And other previous research has found that a positive therapeutic working alliance (which we now know can occur online), not only has a significant impact on positive outcomes (Horvath et al. 2011) but can even override any particular therapeutic modality (see Castonguay et al. 2006; Lambert & Barley 2001). Clearly, there is no reason why an analyst’s already established positive therapeutic alliance with their patients cannot be continued once online work has had to be implemented in response to the COVID‐19 pandemic.

Martin et al. also reviewed the evidence that practitioners can adapt their style so as to enhance the therapeutic alliance by:

providing more deliberate and overt non‐verbal responses, by purposefully exaggerating tone of voice, gestures and mannerisms … actively paying more attention to social cues and signs of emotionality, conveyed through facial expression, tone of voice or body language [and] asking more questions … to avoid misunderstandings.

(Martin et al. 2020, p. 39)

The issue these suggestions raise is that of authenticity as, by contrast and through his discussions with other analysts, Gutierrez (2017) asserts that imposter issues can occur with online work as in a ‘tendency to show themselves to be especially attentive in their gaze and to show themselves particularly disposed to the other in their speech’ (p. 1108). And this often leads to speaking more than usual compared to in‐person sessions. Gutierrez also comments on the effect of gaze, asserting that the screen presence of the analyst’s own image can lead to self‐monitoring, a loss of spontaneity in interventions and an exigency to display ‘ideal’ behaviour, all of which he says, can foment a ‘de‐naturalization’ (ibid.).

Consequently, Gutierrez believes an impoverishment in the quality of the analytic material can occur as in a ‘tendency to literalism and disaffection typical of banalization’ (p. 1109), so that a kind of concretization unfolds, as if the discourse is just a ‘speaking about’ (ibid.). Hence, silences can seem more uncomfortable thereby prompting ‘inauthentic speech’ (ibid.), which Gutierrez concludes can again lead to a concretization that precludes regression. As such, he believes there can be a tendency to escape from such difficulties, as well as to avoid latent conflicts by focussing on a ‘connection problem’ (p. 1115), which can actually be understood as a symbolic statement.

Whilst it is important for analysts to be aware of all the aforementioned advantages and disadvantages in online work (and possibly to discuss aspects of them with their patients), nonetheless, the findings outlined previously do indicate that whatever working online means in terms of what we ‘see’ and ‘do’, the essential components of analytic work as in transference and countertransference phenomena can unfold.

Hence, when working online, conscious adaptation of our style may be worth considering, especially if it enhances the therapeutic alliance, and with regard to that question, the actual use of the screen is an issue to be considered.

Particular uses of the screen

Through undertaking training of psychologists in the use and implementation of telepsychology at Texas A&M University’s Clinic, McCord et al. (2015) have made some very pertinent findings about the ‘picture‐in‐picture’ feature of online work. Apparently, it is useful for practitioners to see themselves in the process as this facilitates cognizance of their body language, to be balanced against the negatives outlined above. However, they recommend that the ‘picture‐in‐picture’ feature be turned off by the client as it has been found to be distracting. They also discuss their findings concerning the advantages and disadvantages of having either a wide or narrow view of the face on screen. A narrow view of the practitioner can give to the client a sense of them being ‘closer’ and can enhance communication of their facial expressions. But this limits any view of their hand gestures and other non‐verbal communications. Similarly, a narrow view of the client gives the practitioner ‘a better view of the client’s facial expressions, but limits the ability to see other non‐verbal cues like body tension or nervous leg shaking’ (p. 338). Alternatively, a ‘wide‐angle view of the client gives … a better overall picture of the client’s body language, but it can become difficult to tell if a client is “silent” crying or see smaller facial expressions’ (ibid.).

By contrast and from their interviews concerning online work, Trub and Magaldi (2017) draw a conclusion that analysts can be left ‘feeling less comfortable in their bodies and more self‐conscious, in part due to the truly unique phenomenon of being faced with their own image on the screen in session’ (p. 224). And furthermore that ‘hearing and recognizing [the patient’s] needs [can look] different by screen than in person’ (p. 228). It is certainly understandable that what we see on screen can be different to what we see in‐person and (as above) it is important for analysts to be aware of all the aforementioned, but especially the possible advantages that McCord et al. (2015) outline. And those advantages can be augmented by the non‐verbal ‘contextualisation cues’ that Roesler (2017) maintains can occur with online work.

Nevertheless, the findings outlined previously do indicate that whatever working online provides in terms of what we ‘see’ and ‘do’, an analytically ‘good enough’ process can unfold in terms of transference and countertransference phenomena.

Trauma can be healed online

Given that current research indicates the COVID‐19 pandemic can lead to vicarious traumatization (Li et al. 2020) and post‐traumatic stress symptoms (Sun, L. et al. 2020b; Yin et al. 2020), it is worth noting that trauma can be mitigated through online work (Merchant 2020). Lazar and Hirsch (2012) found that Holocaust trauma in a Jewish‐Israeli context could be processed through online forums. They discovered that the postings were able to ‘connect the interested auditor and [the] observer to the experiences of the Holocaust survivor by undoing the inherent negation and discontinuity existing in their experiences’ (p. 101). In other words, both a validation of, and a bringing together of the psychic reality of the auditor was progressed, rather than being denied, so that real value flowed from externalizing to other(s) the private experience of trauma. Understandably, such an outcome could also occur in personal online analysis. The second thing Lazar and Hirsch highlight is that the forums turned ‘the passive listener into an active hearer’ (p. 101), which would again align with the empathic work that can unfold in personal online analysis. These findings give credence to the view that any trauma analysts’ patients may experience due to the effects of the COVID‐19 pandemic, can be processed through online work.

The importance of self‐awareness

McCord et al.’s (2015) training of psychologists in the use and implementation of telepsychology at Texas A&M University deduced a number of important clinician competencies to do with online work. In addition to the practical skills needed to navigate modern technology, they also found clinicians’ ‘self‐awareness’ to be important. This is because ‘counselors are people who have their own attitudes, biases, and beliefs’ (p. 329), so it is important for professionals to be self‐aware as to how such biases can influence their practice. They outline one example, in that a ‘counselor’s belief that overdependence on technology is a major flaw in today’s youth may lead to scepticism about the effectiveness of some telepsychology treatment modalities that differ too much from traditional talk therapy' (ibid.). In so doing, they highlighted ‘unconscious values as opposed to research‐informed opinions’ (ibid.). Noticeably, in addressing ethical issues in response to the current pandemic, Chenneville and Schwartz‐Mette (2020) make a similar point that clinicians need to acknowledge their own personal issues, which can include an ethical duty to care for themselves. On the latter, the informative American Psychological Association’s (2020) ‘Self‐care for psychologists during the COVID‐19 outbreak’ document is available in the Public Domain. All this suggests issues on which analysts could ongoingly reflect, since many responses within the Psychoanalytic School, such as that of White (2020), are often personal and anecdotal.

Knowing the predictors of mental health

Yildirim & Güler (2020) found that the best predictors of mental health in response to COVID‐19 in Turkey were a clear understanding of just how severe the impact of the virus could be at the personal level; second, ‘self‐efficacy’, as in the belief in one’s ability to take appropriate action; and last, in initiating preventive behaviours to minimise the possibility of infection. Notably, they found these to be better predictors of mental health than gender, age or chronic disease. Follow‐up research found that certain negative impacts of the pandemic like perceived vulnerability, risk and fear can actually be channelled into appropriate and useful preventive behaviours (see Yildirim, Geçer & Akgül 2020). These encouraging findings certainly prompt a focus for analysts with their patients.

Some potential positives of isolation and quarantine

Whilst the negative impacts of quarantine due to the COVID‐19 pandemic have been researched (Brooks et al. 2020), it is noticeable in China that Lu et al. (2020) found that ‘home self‐quarantine is associated with a decrease in depression and an increase in happiness, while community‐level quarantine is associated with decreased happiness’ (p. 1). This would suggest a positive component of self‐agency, as in being able to take control regarding self‐quarantine, versus a feeling of loss of control, as in an imposed quarantine. This factor needs to be taken into account in terms of patients’ resilience, for in China it was further found that resilience (alongside adaptive coping strategies and social support) was helpful in mediating stress symptoms due to the pandemic (Ye et al. 2020). Hence it would be valuable for analysts to consider for their patients (and themselves) what would enhance their self‐control leading to resilience. Relevant issues that Rajkumar’s (2020) review suggested were time management that maintained a normal life routine (whilst following safety guidelines), gaining accurate information about the disease, addressing stigma issues, having online social connection so as to deal with ‘thwarted belongingness’ (Gratz et al. 2020) and accessing online psychosocial services. Other findings have recommended having a work versus personal space, hobbies (Easterbrook‐Smith 2020), progressive muscle relaxation (Liu, K. et al. 2020), mindfulness meditation, problem solving and coping strategy skills, and physical activity/exercise. In addition, Brooks et al. (2020) from their review would add the following – stress management training and the provision of adequate and professional information. On the latter, Lu et al. (2020) found in China that real‐time informed updates (as well as confidence in the pandemic’s control) led to favourable attitudes that were associated with lower levels of depression and higher levels of happiness.

The above skills can counteract the problem of ‘perceived burdensomeness’ (Gratz et al. 2020), as well as overriding the sense of being vulnerable, at risk and fearful, that Yildirim, Geçer and Akgül (2020) noted can work against COVID‐19 preventive behaviours. In terms of physical activity and exercise, studies in response to the pandemic have found their beneficial effects not only amongst older adults (Callow et al. 2020) but, as Ellis, Dumas and Forbes (2020) found for Canadian adolescents, both physical and productive activity alongside a support network (as in family members) lowered their loneliness and depression due to the pandemic.

In terms of enhancing resilience, an issue analysts could consider is their patient’s personality type, especially their inferior function of consciousness. This is because, as Jung (1931/2015) says, it usually drops into the unconscious and becomes ‘contaminated’ with the ‘slime’ of the ‘deep’ (p. 84) leading to a more primitive and underdeveloped way of functioning. Since the stresses and anxieties generated by the COVID‐19 pandemic will no doubt stir confronting unconscious content, the inferior function could become one gateway through which patients’ resilience is diminished. Given that the inferior function reflects a non‐preference only, and not just a capability, then skills to do with the inferior function can be acquired.

Psychotherapy interventions

We now know researchers are well aware of the range of issues impacting people through the COVID‐19 pandemic, as outlined by Carvalho et al. (2020), Rajkumar (2020) and Torales et al. (2020). These include anxiety, depression, stress, ‘health anxiety’ economic effects as well as vicarious traumatization and post‐traumatic stress symptoms (as noted above), interpersonal and domestic violence (Boserup et al. 2020; Carballea, Rivera & Kendall‐Tackett 2020), addictive behaviours (Sun, Y. et al. 2020a) and substance abuse (Dumas et al. 2020). And one of the most concerning issues is the increased global risk of suicide (Thakur & Jain 2020). Given that analysts’ current patients (alongside new referrals) have pre‐existing conditions that could become exacerbated by the pandemic, more focussed psychotherapy responses may be required alongside work that is primarily analytic (as in ‘evenly suspended attention’). And research indicates that such interventions can occur online, including those which are specifically psychodynamic. For instance, Lindqvist et al. (2020) recently found internet‐based psychodynamic therapy to be effective in treating adolescent depression; their interventions also led to a reduction in anxiety and an increase in emotional regulation and self‐compassion. In terms of analysis specifically, Roesler (2017) elaborates the way others have aligned virtual interaction with Winnicott’s (1958) concept of a transitional space, extending into what he calls ‘interactive imagination’, and that this can lead to positive outcomes such as individuation.

Further to Martin et al.’s (2020) review, they found certain online virtual/digital (V&D) interventions and apps had sufficient psychotherapeutic evidence to be recommended. These were ‘Overcome Social Anxiety’, the ‘PTSD Coach Smartphone App’, ‘Family Matters’ which targets substance abuse, ‘Triple P Online’ which focusses on self‐regulation skills, self‐confidence and antisocial behaviour and ‘All Babies Cry’, which aims to reduce parental stress and introduce positive parenting strategies. Given the mental health issues being raised by the pandemic, it could be useful for analysts to be aware of these tools as an adjunct to their analytic practice.

Specifically, in response to the increase in suicide risk, Klomek (2020) outlines ways that health community professionals can prepare themselves in relation to it, initially by noting that people these days ‘are currently more able than in the past to talk about depression, anxiety, and suicide ideation’ (p. 390), consequently the issue can be raised early with patients. Klomek goes on to point out that today there seems to be less stigma acknowledging negative emotions and that COVID‐19 means that death can be on people’s minds, so this could facilitate directly asking about suicide risk. Finally, the availability of social support and online help can diminish the risk.

Final recommendations and suggestions

The diagnosis issue

Given that many analysts are now being required to work online and thereby taking on new referrals, the issue of the initial assessment of patients becomes important, especially the specification of those who would be contraindicated for online work. Harris and Younggren (2011) maintain teleanalysis is contraindicated with Axis II diagnoses (personality and developmental disorders), severe depression (especially suicidality) and those with unstable personal relationships.

The diagnosis issue has also been addressed by McCord et al. (2015) from their training of psychologists in telepsychology at Texas A&M University’s Clinic. As they say, ‘[t]he client’s diagnosis and risk level must be considered, as psychosis and severe suicidal or homicidal ideation are likely to be exclusionary criteria for telepsychology services’ (p. 337). As a consequence, at their Clinic they undertake assessments using the Patient Health Questionnaire and the CORE‐B, both of which are available in the Public Domain. They are easy self‐report instruments for the purposes of diagnosis but which also, and crucially, contain measures of risk. These could be useful tools for analysts to access in the current pandemic, if they have concern about taking on new referrals who cannot be seen in‐person.

Professional development

A study by Banerjee (2020), that Rajkumar (2020) reviewed, looked at the appropriate role of psychiatrists during the pandemic, and this could be applicable to analysts in terms of their own professional development. The recommendations covered a preparedness to educate patients about the common psychological effects of any pandemic, whilst advocating for their personal health safety behaviours alongside teaching problem‐solving strategies. These recommendations do again raise the issue of psycho‐education and the extent to which analysts’ responses during the COVID‐19 pandemic need to include psychotherapeutic approaches, alongside that which is purely analytic.

Regarding professional development overall, the COVID‐19 pandemic (which is likely to continue for some time), is highlighting the extent to which working online, and the issues it raises, need to be a topic incorporated into analytic training programmes.

Practical and ethical considerations

Previous research has shown that there are a number of practical issues needing attention when working online (Merchant 2016). These include licensing and insurance for overseas work; security and confidentiality of data; the use of a private/confidential space at a set time; informed consent; how to deal with technology failures including pre‐arranged back‐up systems and other means of contact; fee and billing arrangements as well as methods by which to deal with silences; a powerful enough technology to limit drop‐outs; a sufficiently shared language to facilitate communication; attention to reporting requirements and an emergency plan. In addition, and in response to the contemporary situation, Chenneville and Schwartz‐Mette (2020) add that informed consent should include information about the risks and benefits of remote therapy, the limits to confidentiality and the specific location of the participants. Furthermore, Roesler (2017) raises frame issues as in patients sending text and email messages between sessions. Accordingly, decisions and agreements need to be made with patients upfront so that the frame is professionally managed.

Prior to the pandemic, Isaacs Russell and Essig (2020) from their experience had produced a guideline for online work which they distribute to patients prior to the first session. A summary of the critical points are:

• They begin by stressing privacy to be the most important feature for the patient, so a space needs to be organised by them where they are not overheard or interrupted. Preferably this should be the same location for each session. If the latter cannot be the case, then any other location needs to be described to the analyst at the start of the session.

• Second, they focus on comfort and recommend use of a comfortable chair but discourage lying in bed, or on a couch, or on the floor or walking around.

• Third, they suggest the patient to have a box of tissues and a glass of water nearby, but that eating food should be avoided.

• They recommend the putting aside of 15 minutes before the session for an outside walk (if feasible). Similarly, they recommend putting aside 15 minutes after the session for an outside walk (in the opposite direction as before), so as to aid reflection.

• Lastly, all other devices should be turned off and all other programmes closed. They recommend the use of headphones so as to free one’s hands. If audio only is being used, they recommend covering the phone’s screen or, if using a computer, turning its monitor off or darkening its screen.

They have found these guidelines to be useful and productive in enhancing patients’ engagement with online work.

Merchant, J. (2021) Working online due to the COVID‐19 pandemic: a research and literature review. J Anal Psychol, 66: 484–505. 10.1111/1468-5922.12683