The Pandemic, the Protests, the Chaos: A Destabilizing Effect on the Analyst

Abstract

In May 2020, within the cultural and emotionally regressive chaos of the pandemic, the analyst witnessed a violent Black Lives Matter protest. Myriad unprocessed feelings subsequently impacted her handling the treatment of a patient who abruptly left a session to attend a protest herself. The analyst describes her own personal experience and the cascade of events that affected the treatment. She suggests that analysts can be armed with the awareness that enactments are more likely to happen when the analyst, as well the patient, are under extreme duress as is the case in the time of Covid. She describes some of the forces that were specific to this case and her own personal embroilment. She then broadens the discussion to other analysts’ reports of overwhelming pandemic experiences and the corresponding effect on the work. She also elucidates the importance of the frame for therapeutic work.

Introduction

Life can be hard at the best of times. But especially since 2020, analysts and patients alike have lived through excessive turmoil evoking fear, grief and uncertainty that is unparalleled in our lifetime. The pandemic wreaked havoc with our thinking, feelings, spirit, behavior, and sense of security.

As analysts, we may have initially underestimated the impact of these traumatic events on ourselves because we are used to sitting quietly in the face of overwhelming feelings. We know how to experience, observe, and make sense. We expect and assume that our observing egos will be able to take over and help us achieve objectivity. Zerbe noted that during the pandemic, analysts’ needs for self-care may have been neglected representing a “mind-body split [that] is culturally sanctioned and professionally overlooked within our field” (in press).

At this time, we were all forced to react and respond on many different levels. It was personal. It was lived, not represented. Our trusted analytic protocols were not sufficient during this period. We were awash with unprecedented experiences and feelings in response to events that affected everyone—the global culture and environment.

What was the effect on the psychoanalytic stance when the analytic dyad was operating within the equivalent of a building on fire? Are there ways it exerted a regressive force? This paper focuses on a piece of acting out between analyst and patient in early 2020 that was related to the Black Lives Matter protests in the context of the pandemic and impacted an analytic treatment. The issues involved in this specific case example can be generalized to provide learning for all therapists going forward in terms of ourselves and our work. The unmentalized components of the catastrophe represented by the pandemic has had wide ranging implications for all of us.

The first force—on the macro level—was our ubiquitous sense of being thrown off balance due to the pandemic itself. The treatment frame was wildly stretched insofar as we had to immediately distance ourselves from our patients on teletherapy and all the disorganization and discombobulation that represented. Secondly, and more personally, on a micro level, this analyst was inadvertently thrust into a Black Lives Matter (BLM) protest that transmogrified into violence outside her window the next day. The day after that the hyperstimulation from the protests plus the continuous invisible stress running in the background of the pandemic spilled over into her mishandling of a moment in a treatment in which the patient precipitously left a session to join a protest herself. The case had its own complications apart from these specific events, and all of the above conspired to influence the analyst to break the frame, which produced ripple effects in the rest of the therapy.

What follows is an attempt to lay out the perplexing disturbance of a case caused by this traumatic cultural phenomenon. The study is intended to be primarily about the analyst’s reactions rather than a focus on the specifics of the patient. Part I recounts the analyst's personal experience in the protests; Part II presents an overview and reflections on how reactions to the pandemic undermined the author’s ego functions in relation to a particular patient and her process. Part III discusses the impingements of living and working during Covid on psychoanalysts as a group. Our primary holding mechanism, the frame, is discussed in light of the extraordinary changes we’ve had to make to it and how that confounds treatment.

Part I: My Personal Experience

Sunday in the Park with a Protest

From my journal

Sunday, 5/31/2020

Today I went to Washington Square Park to read. It was a beautiful warm day in the midst of the Coronavirus pandemic. It was hard to find a quiet spot six feet from other people, but the atmosphere was peaceful and serene. Suddenly, Black Lives Matter protesters, catalyzed by the murder of George Floyd three days earlier, poured into the park. They chanted and punched their fists in the air: “SILENCE IS VIOLENCE!” Most were white.

The crowd’s energy kindles an abrupt and unexpected reaction within me. I want to jump in and join them; I am suffused with nameless rage. I have gone from zero to sixty for no apparent reason. I would love to let go and scream and chant, too. I’m not the only one. Everyone claps and raises both arms in solidarity with the “don't shoot” meme. Then it hits me—because of Covid and my being in a high-risk group due to age, I am in peril. Many in this very tight throng are yelling and are not wearing masks.

I must get out. But first I have to move through the crowd. I try to hold my breath and I flash on how George Floyd and Eric Garner didn’t have that choice. Violence is very much in the air, so I also have to get out because I don’t want to be caught in the midst of this if it goes out of control.

Riots

It reminds me of joining riots back in 1969 in Berkeley and 1970 at Columbia. The group contagion is instant, overwhelming. It overtakes you. The danger evokes wild feelings. I don't want to get hurt or infected, so I drag myself home. I must resign myself to watching the crowds from my window overlooking University Place.

Hordes of people chant and march toward the park; some wear masks, many also video with their phones. This is freaky! They turn over trash cans on the street corners that border my building, push them into the middle of the street and set them on fire right in front of my building!!!! The smell of smoke seeps in my open window. But it’s OK; it enables me to be part of it. I am full of righteous bloodlust but am also fearful about a bullet coming in through the window. The police are mobilizing. I want to run downstairs and join but I am afraid I'll get sick or killed.

People run south toward the park and then inexplicably charge north yelling triumphantly. They chase the police away in front of them. Some guys have boards ripped from NYPD barricades that they hurl like javelins at the police. A bus stops in the middle of the crosswalk on University Place which effectively blocks the entire street. The crowd cheers. I’m momentarily thrilled; has the bus deliberately stopped there to protect the protesters from the police? But then the bus moves on.

The group flees south once more. I can’t tell if things are escalating or de-escalating because it’s happening in waves. Here comes a phalanx of police—walking, in cars, and on bikes. The officers who walk have batons clenched firmly in front of them in both hands.

Fire

My 20-something woke nephew, Charlie, is staying with me. We watch together from the window. A fire on the street blazes steadily, increasing in size. I become frightened that a building will catch on fire. Mine! A car might be on fire on 8th street, but I can’t tell for sure because my sight line from the window is partly obscured by my air conditioner. Charlie and I debate whether to call 911 about the fires. Charlie doesn’t want to bring in more cops and I agree because we don’t trust them. The fire department seems safer, so I call 911. They patch me through to the fire department who say they will come.

An FDNY truck has already driven by, but it keeps on going, siren shrieking. A few minutes later, the firefighters show up and appear to be walking around the fires. Then another fire truck comes but again my vision is blocked from seeing what is happening.

A huge number of people, mostly guys, show up on Citibikes, or their own bikes or on skateboards. This is a diverse mix of people. Usually, my neighborhood is filled with NYU students, especially in protests, but because of Covid all the NYU students are long gone. I find pictures on Twitter of the corner at 12th street: NYPD vans are on fire. I send the pictures to my friends. I need to reach out.

Blankness

A month into lockdown, I have found myself dismayed and perplexed by my absence of feelings. I assume it is some kind of muffling defense. It's not dissociation—that feels different. It’s not the sensation of my head being disconnected from my body as it was on 9/11 looking straight down Fifth Avenue and watching the World Trade Center buildings burn—until they disappeared.

It scares me now because I am afraid my feelings won’t come back. What might result from being so emotionally stifled? Will I develop physical symptoms or even go crazy? I wonder how it might affect my work with patients, which on the surface seems to continue to be going well. But I'm not sure I'm able to make reasonable observations at this time since I don't have my feelings to guide me.

Feelings Erupt

However, now I am assailed by feelings. The whole time I am immersed in the uprising all I feel is rage, excitement, and exhilaration. Charlie points out that because everyone has been imprisoned for three months while terrified of disease, perhaps more fuel has been thrown on the sparks of longstanding smoldering wrath about police brutality. The energy of the crowd generates a mood of release and freedom.

I feel ashamed that I do not have a whit of fear. I am appalled to find that I am clearly waiting and hoping for things to escalate into more chaos and destruction, and, further, that the thought keeps intruding into my mind that this could not be happening here, in Greenwich Village! Humiliatingly: “This is the land of the gentry!” Likewise, the same voice of shame is running continuously in the back of my head berating me by intoning, “White privilege.” At the same time, I feel proud to live where The People are having their voice. It’s as if I represent the protests because I live here, and Greenwich Village is historically where the Voice of the People has been raised and heard.

Aftermath

The next morning, I look outside to the street. There is not a trace of last night’s destruction. All is calm. A few people are out and about tending to their errands. I take a walk. Two blocks away there are broken windows in various stages of repair. The Verizon store, Chase and TD Banks, and the classy gelato shop are attended by workmen boarding up the empty window frames. I see police cars—their windows are smashed, their doors are hanging open, and glass is sprayed all over the street. An empty space holds the remaining ashes of a charred police car. Tourists are standing around taking pictures and videos. “Fuck the NYPD” graffiti is sprayed on posh building facades.

My building sends out a notice to the residents to stay inside due to the 8:00 pm curfew mandated by Mayor de Blasio. The front door to the building will be locked. This has never happened in my 30 years of living here. I just cannot begin to wrap my mind around what is happening.

Breaking Glass

Two days later, Tuesday, 6/2/20

A friend sends me “Pundemic” jokes. It is hard to laugh because it is so scary here. It seems that fear and exhilaration seesaw back and forth. Last night while I was sitting in front of my computer screen trying to conduct a therapy session, outside people were on a rampage. They crashed into the grocery store directly below my second-floor apartment. I saw and heard it from my window. I didn’t know whether to run downstairs and join the frenzy or hide in a closet. Stores on my street had been boarded up, some to prevent being broken into and some already having been broken into. Helicopters flew around day and night. My head reverberated with the memory of those imposing black military choppers in Vietnam in the 1970s accompanied by Wagner’s (1856) “The Ride of the Valkyries” in Coppola’s film Apocalypse Now (1979).

I was hungry and I wanted to dash out and get some sushi after my last Zoom therapy session, but it was too late. Post curfew. An alert had gone off on both my and my Brooklyn patient’s phones during the session. With six minutes to go, I heard protesters in the street yelling and chanting. Did my patient notice? Should I have asked for her reaction? She appeared to be absorbed in her personal narrative, so I did not interrupt.

I was frightened about whether my nephew, Charlie, and I, were in danger in the apartment. Totally distracted, I contemplated whether to end the session, excuse myself for a moment and look outside, tell the patient what was going on, not tell her, take my computer into a different room, or what?

I was paralyzed. There was no playbook for this situation! The session thankfully came to an end. With my preoccupation split between the events outside and trying to focus on my patient’s inner concerns, I wondered, is this psychoanalysis?

Part II: Effect on Treatment: Sheila

This is a story about a short, six-month treatment.

Sheila began treatment during a particularly vulnerable time for me in lockdown. Despite years of training and experience, I behaved impulsively, wiping out the frame. This was singularly noteworthy to me given my extensive training in both Modern Psychoanalysis that focuses on pre-oedipal phenomena and my professional origins in the field of addictions. I have a special interest in studying and understanding primitive defenses characterized by going into action rather than being able to mentalize and putting thoughts and feelings into words. What happened to me and why? How did the patient’s dynamics contribute?

Is This a Patient?

April 2020

Sheila, a 57-year-old woman, started teletherapy about 2 months into lockdown. She had no prior treatment. Only in retrospect have I been able to unearth underlying factors in her abrupt ending of the treatment. Sheila’s presenting problem was high anxiety which she said “normally isn’t really a problem” but which frightened her during her partner’s recent illness with the Coronavirus. This also came up around public speaking. At this time, she and her 58-year-old partner, Roberta (especially Roberta) thought this would be a good time for Sheila to start therapy.

I missed noting the major resistance—that she came to treatment primarily to satisfy her partner. Roberta convinced her to initiate therapy by tapping into Sheila’s own operating principle that there was something wrong with her if she experienced a strong feeling.

Furthermore, early on she had explained that if she hadn’t had the convenience of Zoom, she wouldn’t be doing therapy. Nevertheless, at the time, I bought into the myth that she was a committed patient perhaps because of my anxiety about maintaining my caseload during the pandemic. I was hounded by a subliminally hovering fear of potential loss, influenced by the horrific news and never-ending wailing of ambulance sirens.

Sheila seemed so earnest about wanting help to understand her overwhelming and disorienting anxiety when her partner was sick. In addition, she was charming, and I was fascinated by the glimpses of rich analytic material she let slip regarding her unpredictably hysterical and demonic sounding father. Moreover, there was a corresponding burgeoning negative transference about my “incompetence” that was tantalizing analytically. Under her extremely polite presentation there were veiled intimations about my not being good enough. Her ongoing seeming disappointment once the treatment unfolded paralleled her description of her feelings toward her father.

I was also hooked by my interest in her brilliant and eloquent deconstructions of the differences between American culture and that of her Eastern European heritage. For example, she pointed out that she would only want treatment to be conducted in English. If it were in her “mother” tongue, she would experience the situation as more judgmental.

Acting Out

Early June 2020

In our eighth session, the day after the extraordinary violence in my neighborhood, Sheila’s partner materialized onto the Zoom screen, whispered something, and zipped out. Sheila looked up at me, saying, “I have to leave right now to attend a rally at the mayor’s mansion.” I responded precipitously and, in effect, agreed with her immediate leave taking: “Do you want to postpone the session for later in the week?” Sheila nodded and we rescheduled for a totally anomalous hour I created for the following Sunday. She took off. I said to myself that these were extenuating circumstances. This was a rationalization. I cannot imagine such rescheduling during “normal” times.

In the Sunday session she recounted having been caught in a protest that became violent. The police hemmed people in, beat them up and arrested many. She was quite concerned because she had a misdemeanor on her record related to marijuana and was afraid of the consequences of a second black mark in her police file. Fortunately, she and Roberta were able to run away. She was agitated as she talked. I felt like I was back in it myself.

At the end of that Sunday session, she canceled the next regular session saying the sessions were too close in time. Instantly, I regretted having offered her the odd hour. In the next usual treatment hour, I broached, “You know, it was my idea to have an impromptu session on a Sunday. Maybe you didn’t want it in the first place?” Sheila waved her hand as if dismissing the whole thing, “Oh it’s fine; it’s in the past.”

I gamely plowed on, “May I ask what’s the problem with having two sessions close in time?” Sheila explained, “As time goes on and we re-enter real life I will want to cut down on sessions because I will feel constrained. I’ll feel like, ‘Oh it’s Thursday, my therapy night and I HAVE to be there.’ I’d rather go out dancing with my friends. I know if I called to cancel, you’d ask me ‘how about rescheduling?’ I wouldn’t want that. I know myself. It’s not your fault, that’s just the way I am.”

I proceeded to act out feelings of anger and impotence, while wondering to myself, does this person even want treatment, saying “If you have a plan to cancel sessions to avoid feeling constrained, we might as well stop now.” Harsh! I thought she looked stunned, though she said nothing.

I managed to cool down and tried to recoup by explaining the theoretical rationale accompanying my outburst. “Consistency in therapy is the foundation for growth. It can be helpful to talk rather than act when a person wants to skip a session.” Sheila again was quiet. At this stage of treatment and at a time when feelings were so high my explanation was completely unrelated to her state of being and flew over her head. I was paralyzed from thinking creatively and empathically of a way to reconnect.

Loss of Analytic Stance

I was impacted by my own experience and the feelings that overpowered my analytic mind. I missed the present multi-determined symbolic message behind her aversion to feeling constricted. In reality, being constricted day after day was something we were all afflicted by. Further, I had behaved in a constricting manner, re-enacting her relationship with her father in the transference. It seems that an overpowering mutual regression created a contagion in which I “became” the father who traumatized her.

Rethinking the rescheduling, perhaps my impulsivity was contaminated by hers. More likely it stemmed from my own fear, excitement, and primordial fury triggered by the carnage outside my window the previous night. Twenty-four hours later, I was still reverberating with feelings too hot to handle that catapulted me into action.

If I’d gone ahead and joined a protest, it might have enabled me to vent my own primal wrath. I’d been inside for so long. I was deprived of my in-person work, of seeing friends, and of the pleasure and normalcy of going to restaurants and shows. It now becomes evident how everyday events had provided stabilizing pillars to our lives, at the very least to our ego functions, thought processes, and sense of object constancy.

On a deeper level the violence of the protests stirred up rage related to my abusive father and a long-repressed desire to get back at him with a show of force. Every hyper-uniformed and over-weaponized policeman I saw from my window easily stood in for the other brutal figure in my life. What is it going to take to overcome the strong getting to overpower the weak?

All these forces roiled inside me. Circumstances beyond my control and my professional experience swayed me to lose my ingrained analytic stance. Slochower (2019) has written eloquently about this phenomenon. I went along with the patient’s abrupt leave-taking in favor of a protest and prompted her to take another session at an hour I would never would have normally given. She, in turn, was swept away by her own overdetermined motivation to cancel.

Sheila running out of the session provoked abandonment anxiety in me. The frame, and work during this time of loss, chaos and danger set up a state of insecurity that made some vestige of keeping the frame (in this case a “make-up” appointment), become more important than honoring her agency around canceling.

Nature of the Acting Out

I speculated that the pressures set off in her were twofold: it was very early in treatment, and she was unfamiliar with therapeutic work as an inexperienced patient. While not yet explicit, she did not want to be there in the first place. It was her partner Roberta who wanted her there for unknown reasons. Maybe the rally was important to her in ways neither she nor I yet understood. She did what her partner wanted, and evidently Roberta wanted her to skip out on the session and go to the rally. Or perhaps Sheila was looking for some excitement to break up the tedium of working from home while missing her co-workers. Prior to this she had not voiced any identification with the BLM movement or interest in political activism.

I was informed by my understanding of the forces that give rise to impulsivity. On one hand, there are certain patients who are fixated at a pre-verbal level of development in which action is a primary means of communication as well as defense against intolerable feelings and also a form of discharge of affects that are too much to handle (Abrams, 1976; Goldwater, 1978).

Additionally, extreme stress at any stage of life can plummet an otherwise more integrated person into a regressive state of black and white thinking and corresponding impulsivity (Music, 2021). I believe it was this state of affairs that drove both Sheila and me into a more action-oriented mode.

Abortive Termination

October 2020

Sheila emailed to cancel 40 minutes before the session citing an opportunity to attend a Zoom meeting for a new volunteer organization. She added a few days and times when she could come but noted she was not free on the weekend. I was confounded. She knew my 24-hour cancellation policy and she did not send the usual payment through her phone app. I understood that she was influenced by the one-time experience in which I abandoned my cancellation policy. Based on my having changed the frame, she now offered some regular and irregular rescheduling possibilities (the weekend). Now I had to do damage control wreaked by my veering so far off course. I was stuck with having to address this intrusive, unexpected issue that had popped into our work! I did not want to get into money or policy issues by email outside the session. I had to deal with having unwittingly conspired with her resistance and had thus sacrificed the frame.

Of course, in addition to my countertransference-powered enactment secondary to my responses to the protests, Sheila’s original ambivalence still held sway, as she’d been effectively mandated by her partner for reasons that didn’t quite make sense to her.

My head was spinning. In fact, not knowing what to do, I rapidly developed a headache upon taking in her email aborting her session. Ultimately, I decided to text back, “Let’s just leave it till next week.”

In the next session I asked, “How did the Zoom go last week?” She basically reiterated, “At the last minute my friend Ruth called and I couldn't get out of it.” Plowing on, I uncomfortably pointed out, “I notice that you didn’t pay for the missed session. I wonder if I’ve been confusing about my cancellation policy.” A reasonable person, Sheila replied, “No, I know what your 24-hour policy is.” I said, “So, unfortunately, I need to charge you for the session. I realize it must feel unfair given that you canceled through no fault of your own.” Sheila, again characteristically waved it (and me) away with her hand, replying, “Oh, no, it’s fine—I get it.”

She went on to have her usual repetitive session focused on surface issues related to work. There was also a subliminal sense that something was amiss in the treatment which I hadn’t figured out yet. And of course, she must have been angry about being charged. In the next session, she showed up in order to quit. Charging her obviously reinforced the resistance she already had to treatment. My efforts to access her anger about that charge which were bound to feel unfair were unsuccessful. However, I believe this early termination was in the wind for some time in addition to the confrontational incident I instigated that led to her quitting. Only in retrospect have I been able to unearth more fully underlying factors in her abrupt ending of the treatment.

Reflection

I went along with her ending as I agreed with her that the sessions’ content was repetitive and perfunctory, and I hadn’t helped deepen it. I put the onus on myself to obviate any feeling she might have that I was blaming her. I also noted silently that she had succeeded in letting me know how incompetent and inadequate I was, just like her father, but we were worlds away from bringing that to awareness. I do wish I had circled back to try to unearth the multiple pieces of acting out. For example, I might have asked:

"I know we’re ending, but I have a question or two that might interest you. May I ask, was this treatment more your partner’s idea than yours? Is there anything you might have wanted to get out of it?"  Or: "When we first started you mentioned the anxiety you had when Roberta had Covid and when you encountered unexpected turbulence on a plane. Was your idea that there was something wrong with your feelings? And that therapy should eradicate such feelings?"

There was at least the shift in the direction of Sheila’s increased autonomy. Characterologically acquiescent to authority figures, she came to assert herself with me, a woman in authority, in this short treatment. To have been able to metaphorically and transferentially kill off the father toward whom she felt ineffectual, may have been exceedingly satisfying.

Case Conclusions

This is a case in which my rational thinking was hijacked at two points. A patient made a seemingly reasonable request for therapy, but I overlooked that she was coming at the behest of her partner. My rational mind went offline at the outset. Secondly, I was overwhelmed by the surrounding political and cultural environment within the life-threatening worldwide pandemic. We all felt unsafe and under siege. The violence, both in the air and in reality, put me into a regressive hypervigilant mode in which I was more action oriented than able to mentalize.

In addition, I had subsequently had a wildly intense experience that overlapped with the patient’s, which led to my suggesting a rescheduled session instead of waiting for the request to come from her. I didn’t have the opportunity at the time to consult with colleagues to gain the control and objectivity that come from processing a difficult situation.

There were at least five levels of destabilizing impact contributing to the enactment in the case: the overarching global pandemic, the protests in my neighborhood, the issues from the patient’s history and current life, the dynamic in the analytic dyad, and the triggering of my own early attachment issues. The latter three are comprised of:

1. the patient’s characterologically avoidant defensive structure leading to a push-pull dynamic in the therapy setting; the trauma she suffered having had to face the possible loss of her very ill partner over a four-week period in the beginning of Covid. NYC was the epicenter of Covid-19 during the Spring of 2020, with 4 to 5 thousand deaths a day. Sheila experienced terror, helplessness, and uncertainty from the beginning. She must have feared that she could get sick as well. Her having been pushed into treatment and her desire to leave in a way that wouldn’t hurt my feelings made dashing out to a protest acceptable to her under the circumstances.

2. A dynamic in the treatment in which Sheila’s unspoken wanting to leave triggered my counter-response to chase. This created an avoidant/anxious attachment dynamic between us.

3. My own early anxious attachment wound was triggered by the similar overarching fear and helplessness that everyone was subject to in pandemic life. This became acutely activated by an at first subliminally, but then overtly, fleeing object.

Regressive Dynamics

I was subject to the protests in my neighborhood and corresponding immediate threat to personal safety. At the same time, I had a conflict as I wished to join in. I was deluged with the contagious rage in both the here and now and from my history. I was also angry and frightened about both the political situation and the pandemic. I went into an action-oriented mode that precluded any possibility of mentalizing and containing. This is the kind of regressive motion, much referenced in trauma studies, that catapults the individual into concrete thinking that can lead to action, and which freezes the capacity to mentalize (van der Kolk, McFarlane & Weisaeth, 1996; Hill, 2015; Schore, 1994). Precipitous action tends to move in a destructive direction. “To create—whether it’s a new watch or a new life—takes longer than to destroy” (Goldwater, 1994, p. 21).Some old and new humbling lessons emerge from this experience that inform my teaching and consultation practice:

1. Don’t go into action when feelings are high.

2. Keep in mind that when a patient comes in to satisfy someone else, they are entering into treatment with a built-in destructive resistance. They already have one foot out the door. Focus as soon as possible on that.

3. The analyst is fallible; sometimes we’re going to make mistakes, and that’s how we learn; we are all subject to creating enactments or acting out when overstimulated.

Most importantly in this case was the overarching impact, conscious and unconscious, of doing therapy in the time of Covid. “It therefore leads to the expanding literature on how Covid- 19 affected our practice and attunes the clinician to slow down and expect enactments when a worldwide cataclysm occurs” (Zerbe, personal communication, March, 2022).

We can't minimize the impact of the stress we’ve all been subject to during this awful time. But we can use it to learn by reflecting retrospectively and fortifying ourselves with anticipation of what could happen.

Part III: General Considerations Regarding Treatment in the Time of the COVID-19 Pandemic

Pandemic Fatigue

How can we make sense of the incomprehensible? What, exactly, was (and at the time of this writing, still is) the inchoate intrapsychic and somatic impact of living in a chaotic dangerous environment and working in a virtual world with a dramatically changed frame, and within the reality of the trauma we shared with our patients?

How did pandemic induced stress, also dubbed “pandemic fatigue” (Zerbe, 2020), manifest? Some of it has been more tangible, like the cognitive problems many complained of, such as forgetting things, making mistakes, having trouble finding words, distractibility and not knowing what day it was. Other regressive manifestations have occurred in the body and the psyche—that of experiencing anxiety, depression, suffering accidents, pain, or actual illness. Zerbe (in press) noted, within her treatment and supervision practice, reports of changes in “sleep, energy level, exercise and eating patterns and somatic reactivity.”

Anecdotal reports from colleagues and patients included attacks of colitis, non-Covid respiratory issues, muscle spasms, falling and breaking bones or teeth, and more. There was also hypochondriasis, focusing in on any possible symptom, out of terror that it was incipient Covid, especially before the vaccines.

Some reported unexplained surges of rage that leaked out into fights and arguments with friends and family. It wasn’t unusual to have an extreme reaction to minor technological quirkiness such as the screen freezing, looking up the other’s nose seemingly a few inches away, hearing clicking or rustling noises secondary to the other’s mic rubbing against their necklace, getting seasick when the patient Zooming from their phone is moving their screen around, etc.

Harris vividly depicted our “new normal,” a kind of physical regression of sorts in which she was

noticing and tracking all too frequent falls and tumbles…. Bones cracked, bruises, unsettling moments of disarray and confusion. I think this is one of the unexpected results of our long hours of sitting, our immobility, the work on screens that reduces our sense of dimensionality and movement in space (Harris, 2021, p.100)

We are now mutually confronted with the inevitability of death as real and immediate. It is no longer possible to deny or avoid whatever we’ve thought death was; it’s here. Rose points this out while noting that our former ability to tune it out “which may seem to be the condition of daily sanity—has been revealed for the delusion it always is.” This is a pretty scary thought! She colorfully elaborates that “In the midst of a pandemic, death cannot be exiled to the outskirts of existence. Instead, it is an unremitting presence that seems to trail from room to room” (Rose, 2021, para. 3).

Long before Covid, analytic writers were already documenting the difficulties of working remotely (Essig, Turkle & Russell, 2018; Bayles, 2016, to name a few). Now there was no choice. These are some of the burdens that therapists had to shoulder while working (See Harris et al., 2021). How could we contain our own engulfment as well as that of each idiosyncratic patient?

Changing the Frame

In order to unpack what happened in the case resulting from numerous breaks in the frame, it will be helpful to consider the meaning and use of the frame. This case was impacted by a number of changes to the traditional frame—one being pandemic induced--zooming from the therapist’s and patient’s homes, instead of sitting together in an office, and the other, even more outside the box, both therapist and patient unexpectedly and coincidentally being swept away, albeit each quite differently, by involvement in Black Lives Matter protests within the larger context of the pandemic.

It has been said that the set-up of the therapy process—in a room together, at a stated time, with a stated frequency, a fee, and a mutually agreed upon goal—provides hearty leverage for the work of therapy. That form, the frame, plus mutually positive intentions, creates a space for the work to happen almost irrespective of the content of what is said (R. Unger, personal communication, March 17, 2019, as noted in Frankfeldt, 2020).

The frame is at once a sturdy yet pliable mechanism for enabling analytic work to take place. Many forces come to bear on its form and flexibility. Prior to Covid, much had been written on the importance of the frame even before it was drastically altered by our not being able to meet in person. A quick search in PEP-Web yielded 12,803 results of its being mentioned. It is a complex entity which will be helpful to examine in more detail in order to think about the effect of its alteration during Covid in general and the acting out in this case, specifically.

We think of the frame as the structure that establishes an atmosphere of safety for both patient and analyst necessary for promoting the therapeutic relationship. Its rules are both implicit and explicit. The contract between therapist and patient is explicit and consists of an agreement about frequency, fee, when the fee is to be paid, and length of the session. Sooner or later, depending on the therapist’s judgment, confidentiality and cancellation policies will be discussed. It may or may not include a plan for use of the couch. Until more recently it was understood that sessions took place in the therapist’s office. The office was a crucially significant part of the frame.

Additionally, and concretely, the frame, as exemplified by a brick-and-mortar office, creates an implicit boundary between the inner (analytic) and outer (reality/environment) worlds. The space provided by the frame is conducive to a safe regression to intrapsychic, early developmental states which can then be experienced and put into words. It is through this means that we have an avenue to making the unconscious conscious.

Another aspect of the analytic situation enfolded within the frame is the emotional power differential created by one person asking for help and the other taking on that facilitative role. The analyst defines under what circumstances this will happen: use of the office, payment of a fee set by the analyst, use of a time within the analyst’s working hours and sometimes the analyst’s sitting up while the patient is lying down. The tension created by the asymmetrical balance of power provides another vehicle for the fostering and analysis of transference, countertransference, and resistance as they develop.

It is this space that allows for enactments which provide more opportunity for studying and understanding the patient’s and analyst’s co-created dynamics.

Until recently, the frame, and especially the holding space provided by the therapist’s office, further established an implicit as well as real separation of the outside world from the inside world. As such, the office was beautifully positioned to invite the patient to move from an external/reality focus to an internal/transference-oriented focus uncontaminated by everything going on in the outside world. Theoretically, at least. Of course, we know there is no such thing as complete lack of contamination, but there is still a big difference in the conduciveness to free associate by being in a quiet, non-stimulating office atmosphere versus sitting in a car by the side of the road with traffic whizzing by, neighbors stopping to say hello through the window, while notifications are going off on the screen.

What, in fact, was the effect of the plethora of changes, violations even, of the frame on treatment? We have done it as a matter of course; we had no choice. But given it is precisely the structure of the frame and the therapeutic leverage afforded by analyzing changes to the frame, that is the bottom line of treatment, how do we assess what is lost when the patient is sitting on the floor of their relative’s bathroom, worried that their spouse or parent or child can hear their bitter complaints, while we are on the other side of the Zoom room, perhaps also worried about who in our house can hear what is going on in the session?

In an ideal world, the analyst is unencumbered by personal problems, emergencies, physical pain, etc., so that we can focus on the patient’s communications and our corresponding associations and fantasies. Maybe this is rarely the case! But we do have an assigned role and purpose. We strive to bring our best effort to look at our mutually created dynamics and what that tells us about the patient for the benefit of the patient's growth.

Extra Analytic Self-Disclosure

Analysts found themselves breaking the transference by engaging in self disclosure as a matter of course. When physical and/or psychic survival are at stake, more existential questioning goes by the wayside.

We were faced with myriad interactions in which we had to make a choice. Should we be dealing on a reality level or on one which would access an underlying historically-based conflict or anxiety? Under “normal” circumstances the choice would be easier depending on factors involving the patient’s developmental level and time in treatment, but the Covid lifestyle introduced an added feature that could make delving crass and inappropriate. How would we make these decisions and how would we know to what extent they were made based on our own active anxiety?

In a discussion, Dr. S. Sherman postulated that being “all in it together” prompted therapists’ reasonable urges to self-disclose (S. Sherman, personal communication, February 2022).

In an email communication M. Cohen, LCSW, added that

We therapists are more deprived of our usual friend and family social interactions because of Covid isolation. We are more likely to “use” our patients to satisfy our social needs as we ourselves are hungrier for connection. We are also working harder to foster and maintain a connection with our patients through the medium of a computer screen (M. Cohen, personal communication, December 2021).

Previously, she wrote “We are striving to have three dimensional relationships in a two-dimensional space.” (Cohen, 2020, p.17).

Effect of Zoom on the Frame

The switch from face-to-face talking therapy to e-therapy has hardened the therapist’s ability to create a safe and containing space, as Mateescu (2021) reminds us.

In online therapy, the physical therapeutic presence, which is regarded as a critical element in therapy efficacy, (Geller & Greenberg, 2002) needs to be rethought. Along with these elements, the self is negatively affected in online therapy, as it becomes a “disembodied self” (Weinberg & Rolnick, 2020, p. 6). Conversely, Lemma (2017) argues for an embodied presence/self in online, mediated therapy, the difference lying only in the way we perceive and experience it (Mateescu, 2021, p. 114).

What happens when the frame is drastically changed and takes place within the shared experience of the patient and the analyst in the context of chaos and danger in the world?

What is the effect of working from one’s bedroom within the eeriness of a virtual background? How does it affect the patient to see the analyst’s hair or earrings disappearing and appearing if we move our head? A colleague labeled this phenomenon “psychotic” (N. Stiefel, personal communication, June, 2021). Are patients supposed to be able to put into words what that does to them? Would it be disruptive to ask? Generally, we would wait until the patient brings it up, but in the two years of working on Zoom no patient in my experience has commented on the visual peculiarity of “Zoomness” in treatment. Why is this?

Chaos

A quick Google search (Oxford Languages, n.d.) of “chaos” produced: “complete disorder and confusion.” This aptly describes our collective experience during the first few months of the pandemic given the political situation, the invisible but ever-present disease and the BLM movement. Our societal infrastructure, the larger “frame,” was shattered to a great degree. Some reacted by isolating psychologically as well as physically, while others of us reacted by wanting, by any means, to move closer to others. This produced both a tension and a tension-relieving mechanism in online therapy.

The hierarchy that previously existed, for better or worse, was also eliminated with respect to our shared circumstances. This, again, could be experienced paradoxically as both destabilizing and reassuring. But how to parse this as a clinician?! On one hand it meant making concessions within the frame and our accustomed discourse and on the other it meant attempting to maintain what we could of a frame that would still enable analytic work to take place.

The internal tension and feeling of helplessness, one of the most difficult and painful feelings that we, as helping people, can undergo (Hoffer & Buie, 2016), produced more stress. I believe (and based on anecdotal evidence in addition to my own experience) that this created the potential for more enactments to take place than would be true in normal times. On the other hand, this struggle opened up the possibility for creativity between analyst and patient to co-create a generative space. New meanings would be bound to result from observing, reflecting and mentalizing together about the larger environment.

Coping Constructively

We can't minimize the impact of the stress we’ve all been subjected to during this awful time. But we can learn from it by reflecting retrospectively and fortifying ourselves with anticipation of what can happen moving forward.

Bion (1970) pointed out that “catastrophic change” occurs after a crisis in which there is an unexpected loss of something we rely upon. What does this change look like? Is it good or bad; constructive and/or destructive? As difficult as it has been, it is also possible that as individuals and as a group we have opened up new tracks to treatment, just like new neuronal pathways.

We may still be too much in the midst of the storm to be objective. This is an evolving process. People are regularly sharing and conducting webinars on the value of mindfulness, walks in quiet, lush natural settings, taking up hobbies, taking a break from the news, learning how to start new healthy habits, and curtailing counterproductive old habits. One thing that differs in these times is the proliferation of sites proffering advice about self-care. “Intensive self-care” might be more appropriate, especially for those in the mental health field.

Garnering support from colleagues, friends and family is imperative; providing support can be strengthening as well. Activism can boost feelings of efficacy. Each of us finds our own favored methods.

At times it may be easier to withdraw and isolate to protect oneself, and sometimes this is necessary. Yet in the long run this is antithetical to our work. Additionally, it is all too easy to “use” the patient in our own interest; although, as has been said, it is natural, human, and often therapeutic to acknowledge with patients our shared situation—there is a fine line to consider in making that judgment.

The most powerful antidote to dealing with the internal chaos the real-life situation has imposed upon us is, as always, talking. Individually and in groups, sharing our conflicts as practitioners helps. Many groups both leader-led and peer-led have sprung up to provide support. No less important is discussing with the patient the effect of any confusion, enactment, or outright acting out on the therapist’s part on the treatment. This is invaluable and growth enhancing for both.

Conclusion

In Part I, I describe my personal experience in a Black Lives Matter protest that became violent at the very beginning of the Covid-19 pandemic. Part II recounts how this confluence of overwhelming events had the effect of overriding my efforts to hold the frame with a patient who was ambivalently in treatment. Part III elucidates more generally how analysts were impacted by the chaos affecting the way treatment was conducted during Covid. Of particular interest, and highlighted throughout, is the way the psychoanalytic frame was muddied by moving to online therapy. I point out the myriad ways that the frame has been distorted out of necessity and how that can add to confusion in an analysis. This is a stressor that we as analysts must contend with in everyday life and work. I talked about some ways we might take care of ourselves.

So far, the analytic community has been able to put into words external manifestations of how we have been impacted as well as venturing into the somatic (Zerbe, in press). There is so much more that is as yet unknown.

Perhaps I have raised more questions than I have answered. We’re currently in the process of studying and evaluating as we evolve through this ever-changing landscape, inventing new ways of functioning within a new analytic form. Will some good come of this? Might we track post-traumatic growth? (M. Cohen, personal communication, February, 2022).

It is going to take time to process and understand what we’ve been through and how it has shown itself in each of us. We have the tools of awareness and self-analysis in addition to that of leaning on colleagues and mentors for help. It is essential that we keep striving to make sense of our experience for our own sakes as well as that of our clients’.

Note

1. Valerie R. Frankfeldt, LCSW, PhD, is the former Director of Training and current faculty member, supervisor and training analyst at the Psychoanalytic Psychotherapy Study Center. She is a Certified Imago Relationship Therapist and Modern Psychoanalyst. Dr. Frankfeldt is a graduate of the New Directions psychoanalytic writing program, focusing most recently on the dilemmas posed by the intersection of technology and psychoanalytic treatment. She is in private practice in Greenwich Village, working with individuals and couples and providing clinical case consultation.