Pandemic psychoanalysis

Abstract

Our clinical practice is contextualized by a co-participant trauma constituted by a confluence of upheavals–pandemic, politics, an epistemological crisis, pervasive distrust of expertise and evidence. Psychoanalytic work, parallel to the external world, has become defamiliarized, if not, at sometimes unrecognizable. The affect on the frame and the boundaries of the therapeutic frame and of the psychoanalytic institution are explored with an awareness of the uncertainty of the future. The experience of the onset of the pandemic is discussed with awareness of an unknown future.

Introduction

The impetus for this essay was the shift to remote practice necessitated by the COVID-19 Pandemic which immediately is ensnared in a web of associations to the impact of the external world on the private world of the psychoanalytic encounter. The temporal orientation of psychoanalysis is long term. However, the subject matter here is consistent as much with the time sense of journalism as history, with a mood influenced by intense, rapidly unfolding, changing events; a rollercoaster of intense affects cascading rapidly through darkness with perspective difficult to achieve. Psychoanalysts habitually work with history as a force invading the present but not as an ongoing dynamic vitality that defines the lived present. Multiple revisions of this paper were necessitated by ideas modified by unfolding events: the vicissitudes of the politization of the coronavirus, the context of the 2020 election, and the attempts to overturn it; each new iteration of disruptor events, a worldwide pandemic, a dramatic disruption of political norms and moral assumptions tearing the fabric of familiar culture and, not the least, an epistemological crisis. All of these constitute a “third” in the room, enveloping the dyad, none of these unprecedented, but perhaps unique in their confluence.

Psychoanalysis came into being in the midst of a scientific and technological revolution and itself constituted a major revolution in thought but the current communication, information, technological explosion anticipates a singularity redefining the definition of humans (Kurzweil, 2005; Harari, 2011) and the reality they inhabit.

The questions that force themselves on us include: How is psychoanalytic practice, its procedures, intentions, goals, to be located in a surrounding environment that is neither average nor expectable? What bearing does the Zeitgeist have on the two-person encounter? If some consistency and security—a sense of safety and trust—is a requirement for therapy, can therapy occur in a context of actual, as opposed to re-lived danger, uncertainty, or unpredictability? In other words, if arguably psychoanalysis involves an encounter with early trauma, what is the challenge if it occurs coincident with an ongoing trauma? And if that trauma is simultaneously endured by both patient and analyst?

While the impact of COVID-19, which has introduced basic modifications to practice, is the most immediate stimulus for this essay it is not the first worldwide plague psychoanalysis has seen. Indeed, the flu pandemic of 1918–1920, spread by returning soldiers, took Freud’s daughter, Sophie, along with fifty million other souls. Psychoanalysis in its century-plus history, has been practiced in times of extreme stressors and even multiple identifiable historical novae.

Superimposed on the daily disruptions of how people have to live their lives as they negotiate adaptation to the threats of a deadly disease that is as confusing as it is contagious, there is the disorientation of the anarchism and nihilism, the radicalism and authoritarianism of the now ex-President who continues to be supported both by frightening cultists and conventional opportunists. The drama of the 2020 election and the chaos left in its wake converges with the existential threat posed by the plague. Not only is the rapidity of change traumatically destabilizing but it is also layered on top of structural disruptions that predate them and which provoke massive anxieties—political upheaval, climate change, geographical disruption and mass migration, the threat of terrorism, to say nothing of reconsideration of what it means to be human and lastly, but not least, what Baudrillard (1996) called the “perfect crime” (i.e., the murder of reality).

This isn’t to say that that psychoanalysis has not previously had to respond to elements of these crises. It was birthed during upheavals in thought brought by scientific and industrial revolutions. It was witness to the rise and fall of totalitarian ideologies, of Communism and Nazism, along with a host of nationalist movements; to economic collapse, the Great Depression; to the specter of apocalypse through nuclear annihilation. This time however does seem different, possibly because we’re living through it but not remembering that we have survived it before. Maybe the difference is that we greeted the new millennium having, arguably, just finished the best of times (Pinker, 2011), a period of prosperity and peace heralding an optimism reflected in globalism and Fukuyama’s (1992) pronouncement of the end of history. Perhaps the sense that this time is different comes from the convergence of multiple staggering factors. Most immediately and obvious is the spread of the novel coronavirus. At its heels is the worldwide rise of dictators, exemplary or putative, the immediate threat to the idealized norms of democratic practice in the United States in the demagoguery of Donald Trump, chilling not because of being articulate but because of its acceptance by a significant percentage of the American people. The undermining of trust in authority, cherished values and core values basic to American identity is caught in this maelstrom. It reveals the ugly side of American history, especially as nauseating racism and economic inequality are forced into prominence. In the background, below the surface of everyday awareness, is a challenge to the concept of what it is to be human brought about by technological growth, artificial intelligence, AI, and of course biotechnology (Harari, 2011, 2017).

In this paper I talk about these crises invading clinical practice either explicitly or providing the atmosphere for the treatment, the specters of the apocalypse providing the light illuminating the session.

COVID and recognizability of the treatment situation and the world

In over forty years of practice, I have never experienced a time resembling the past year. The closest, perhaps, is the traumatic experience shared by patients and therapists after the Twin Towers were felled a few miles (80 blocks) south of my office in New York City on 9/11 (Gensler et al., 2002). The period was the first time I was acutely, unavoidably aware of living within an external reality which stimulated a closely related complex of emotions in me as in my patients. Though this is a personal reflection, discussions with many colleagues cutting across theoretical schools, reflects all of us living in a traumatic here and now, experiencing related feelings.

Although I, over the course of many years as a therapist, have changed dramatically, have had to adapt to the vicissitudes of the place of psychoanalysis in therapeutic practice and intellectual thought, to the unique nature of each therapeutic dyad, my only-one-year-ago self, let alone my 40-year-ago self (even having practiced therapy over the telephone as dictated by circumstances), would hardly recognize my practice over these past year and a half. Together, patient, therapist, and COVID have bent the simple therapeutic frame into odd shapes. While, maintaining both a respect for the frame and the value of flexibility, the current physical parameters of a session have transformed what was once unusual, if not inconceivable, into the daily normal.

In March 2020, I stopped in-person sessions. Discussion with colleagues and patients generated much uncertainty. First was some discussion the risk of contagion, the experience of being “locked down,” confusion about danger, questions about when to shift, to what alternate medium, and many questions about how long it would last. Many thought the lockdown would be temporary, few thought it would be long term or indefinite. Mundane practical concerns were balanced by the various meanings the shift from in-person to virtual contact might have. Awareness that each of the alterations of space have psychic reverberations had to be kept in focus. Basic decisions about the set-up are de novo and thus, not having the imprimatur of tradition, are more mutually negotiated, individual, and revealing. For me, establishing the new setting independently highlights the idiosyncrasies of my conduct of therapy, a new kind of ownership of personal responsibility for decisions and judgements separated from the guidance of collective consciousness and norms of the profession.

As far as I can tell, the general decision in New York to suspend office sessions was tentative. Colleagues “felt their way into” the changes. It unfolded with growing awareness of the danger of the virus; and ultimately the relief of being able to fall back on an official mandated lockdown. The anxiety about tangible change was as great as anxiety about intangible contagion which actually felt less real. As practitioners caught up with the new clinical reality, the clinical implications and psychic meanings of working remotely, including the transferential and the countertransferential, started to emerge.

Obviously, the physical surrounding introduced brand new variables. Where the office was a formal setting, patient and therapist now moved to a virtual setting. In so doing, we entered each other’s spaces even when we didn’t know where the other was physically located. Physical space constitutes a gateway to psychic space, delineating boundaries. Where before the patient came to the therapist, now there is a “meeting in the middle.” Because both patient and therapist participate in new experiences, both of the radical disruptions of everyday life and of the novel setting, the degree to which the therapist shares more personal experience constitutes an entirely new kind of self-revelation and mutuality. Patient and therapist become witness, to a greater and lesser extent, of each other solving problems each has met for the first time. Many patients miss the psychic functions provided by travelling to and from the office and particularly the experience of being in the waiting room. Depending on personal circumstances, some patients must find a space to have the session; they leave home, have the session in a park or parked car. Others worry about privacy or being overheard and even the presence of a spouse or child in the home may evoke fantasies and further reveal features of the relationship to people in the home which might otherwise remain hidden.

One of the shared new experiences is a disruption of the sense of time in life including intervals between sessions. It is frequently observed that during COVID, (the expression “during COVID,” itself expresses a new temporal sense) the concept of time was altered. For many work, social, and recreational markers of time have been erased or altered and some people have the experience of living in a time warp. Months fly by. Patients comment that no time has elapsed since the last session and end sessions by saying, “See you in ten minutes.” The 'meme' blursday came into being. The sense of time passing has as its corollary the sense that nothing much has happened—fewer personal events and fewer new events. The exceptions were events on the public stage, non-personal but nonetheless impactful and these were intense.

The changed setting inevitably has an impact on the therapeutic relationship; it affects the structure and cadence of interaction. The subtle communications for which timing is essential, affects attunement, the mutual regulation of interaction, and the timing of interventions, clarifications, reflections. The chance of misunderstanding can be heightened or surprises can evoke new insights and intimacies. For example, silences on the phone, highlight discreet moments and overall flow, as they do in person, with the interesting existential possibility that occurs when the call has been dropped and there are now multiple meanings of the question “Are you there?” Wrapped up in that question are various dimensions of attachment ranging from longing, to abandonment, and/or loss and also, perhaps a paradoxical intimacy. The latter deriving not only from the sharing of the common experience of life during the pandemic but also as expressed by a patient who uses earbuds and describes experiencing me as being “in his ear.”

The content of sessions undergoes changes that reflect alterations in the structure. Patient and therapist must adapt to new unprecedented situations—from basic decisions, such as obtaining food, to decisions about going to work in person, traveling, socializing, dating, all in unprecedented ways and these become subjects which invite co-participant problem-solving, though neither has had prior experience. So, too, circumstances where direction might be called for are changed by the new setup. For example, risks that are apparent to the therapist need to be actively brought to the patient’s attention. Given the influence of peer behavior, the opportunity and challenge is to create a reflective attitude about the influence of others—friends, neighbors and relatives—on the person’s own risk tolerance and surrender to unwise temptations.

Sessions may be more mundane, but less quotidian activity also increases focus on thoughts and the inner life and potentially the experience of the therapist and therapeutic relationship. Because both patient and therapist share so much in the way of new experiences, adaptations to daily living and deprivations, the degree to which the therapist shares personal experiences constitutes an entirely new kind of self-revelation in which the therapist may not be protected by privileged expertise. Then, shared experience makes awareness of boundaries even more important.

The specific problems brought by COVID are varied. Isolation, claustrophobia, and then agoraphobia become relevant. A priori assumptions about life in COVID are sometimes borne out and sometimes not. Certainly, the anxiety over contagion, loss and grief are prime subjects. Conversely, strains are produced in relationships by enforced closeness to significant others that is not diluted in previous ways, or from the blockades to routes of escape from claustrophobia. For patients whose social world shrinks, their longing for connection may become an issue; for those who live alone, the connection with the therapist and the therapeutic function of just being present may acquire more importance. On the other hand, for some, the enforced isolation brings the comfort of being freed from social demands and they escape into agoraphobia. The therapist, if not careful, can become an unwelcome intrusion. It is then the therapist’s task, using therapeutic tact, to obtain consent to widen the patient’s worlds.

One of the unique features of exploring the effects of this pandemic, is that it inevitably leads to a consideration of the nature of inner and outer reality. One might go so far as to say that the virus is a fractal and its outlines reproduce the contours of reality. It is mysterious, often invisible, sometimes harmless, and its course is unpredictable. Its form is perfect for the spread of misinformation in the service of political or other forms of influence. It produces helplessness. Its existence can be doubted and/or denied by people who have not experienced direct evidence of it even as it is clearly killing others. Should it be acknowledged, then rationalized as just another risk we take as the price of living? Paranoia can attach itself to opposing perceptions of it. What responsibility do people have for others? Must we sacrifice for others at the expense of our businesses or livelihoods; or even at the inconvenience of wearing a mask? Like other personal experiences that come up in treatment, the pandemic can be viewed from many angles and evaded in as many ways, too.

Our COVID-induced therapeutic situation requires us to see therapy differently. Similar to the artistic technique of defamiliarizing, that some may utilize to experience art, we must now view what has been familiar and well known to us in a new light and, thus perceive it afresh: distilled to its essences and now, somehow different.

Political anxiety: the social landscape

Pandemics, throughout history, are associated with social consequences: scapegoating, persecutions, religious frenzies, moral panics. The current pandemic is associated with an explosion of right-wing extremism and a plague of bizarre conspiracy theories. A significant number of Americans believe that COVID is an elaborate hoax promoted by a cabal of pedophiles seeking world domination. These Americans, subject to the techniques used by real sexual predators, have been “groomed” to suspend critical judgement and reality testing and accept “alternate facts.” Thus, COVID-related issues, per se, do not end up being the modal content of sessions. Rather, it is the shared extraordinary political environment that generates intense affect.

The former US president is a dramatically evocative and toxic figure. Although there is nothing new about political figures promoting deceitful perceptions of themselves, propaganda and misinformation are key components of their toolkits, the former president has never relented on his lies and has continuously challenged our sense of reality. He flagrantly and insidiously, to use a neo-Kantian term, “radically,” wages war against the idea of truth itself which increasingly becomes defined in the totalitarian sense, as constituted by loyalty to the leader. Partly mad king, partly cult leader, partly hypnotist (Adams, 2017), he stimulates delusions and delusional thinking which erupts from deep and dark unconscious pools. The Trumpian disruption of norms is distressing, but more so is its acceptance by a large segment of the population (Prince, 2018). True, there are some patients who do not seem to be particularly threatened, they are disinterested in politics or preoccupied with other matters, but the majority I see and hear about are frightened and bewildered and bring the news of the day and the latest outrages into sessions. Again, I am a co-participant and aim, not always successfully, to make links to transference and personal history. I justify my involvement in these discussions with the idea that the world of misinformation, avowed alternate “facts,” bizarre, delusional conspiracy claims that have been allowed to enter the mainstream by successful politicians and business people, and the bullying threats of violence, constitute nothing less than true and serious trauma.

Established institutions play a vital role in stabilizing our psychic lives and provide a moral compass necessary for the maintenance of a coherent self. The anarchistic threat to our democracy is existential and it is expressed in an anguished search for explanations that increasingly characterize our discourse. The underlying nihilism, even disguised by slogans, is corrosive. Patients ask my opinions, I think, to help them survive the fog of mystification that engulfs them almost as a poison gas. Though I can’t answer their questions, I can at least explore them with my patients. And this is absolutely a co-participant project. There is an objective reality here, not false equivalences. A proper objective of therapy is to bring to bear the tools of observation and analysis, to look at the reflection of logic in the mirror of intense affect, not to impose opinions one way or another, but to confront mystification brought about by the assault, from any direction or media, on the narratives we tell ourselves about “the facts.” It is a legitimate goal of therapy to navigate the territory between inner and outer reality. A condition for achieving that goal is the legitimization of authority. The current traumas take place in a context that deepens the need for legitimate authority because there has been an overall assault on all authority, including, and maybe especially, professional expertise. We have learned that PTSD is potentiated when the person is failed by the surrounding authority. The principles of reflective neutrality, which were the bedrock of psychoanalysis, require us to carefully rethink our criteria for authority.

I am always mindful about using the power of whatever authority has been invested in me to impose my beliefs. I try to recognize where I am not an expert but only informed and worse only opinionated, but I find it both appropriate and mandatory to help make sense of a world that has clearly gone mad. This obligation creates a paradoxical situation of challenging established political authorities who find it in their interest to support delusional conspiracy theories like those espoused by, for example QAnon. While ideally committed to neutrality, I must also be committed to reality and to taking responsibility for a firm position, which also recognizes that an ingredient of the traumatogenic stew is a failure of consensual validation that certain beliefs, even when shared, are in fact psychotic.

In contrast, news outlets and social media are designed to profit from sensationalism and outrage; thus, they are in the business of amplifying anxiety. Their screams of impending Armageddon, aimed at magnifying the threat to protective social institutions, demand that therapy emphasize its corresponding containing function. Similarly, the political surround has an insidious pathogenic influence that needs the countervailing vaccine of facts, which professional therapeutic discourse should provide. The assault on long held values and beliefs, the moral erosion caused by a culture of mendacity among authorities undermines the self and the repeated example of perception of reality subordinated to wish and corruption undermines the person. It is as if with the smashing of the moral compass the person is lost and therapy becomes the training ground for finding a new sense of direction.

The psychoanalytic “Institution”

An exploration of “pandemic psychoanalysis” must include consideration of the location of clinical practice within the encompassing psychoanalytic institution (i.e., in the collective, formal and informal, of the psychoanalytic world). Psychoanalytic identity is certainly based on diverse strains of thought and includes such a wide range of possibility which, if not entirely coherent, is certainly recognizable. If the impact of massive threats of disease and of environmental and/or political forces has been felt in day-to-day psychoanalytic practice, how could the superstructure of the field of psychoanalysis be immune? Furthermore, how can there not be a reciprocal influence between individual practice and the broader field? If each treatment rotates like a planet around the larger sun, light must eventually penetrate its atmosphere.

Conflict has always characterized the social world of psychoanalysis and there is a long and sometimes surprising, sometimes shocking, history of psychoanalytic beliefs and psychoanalytic groups interfacing with and being influenced if not blown about by political winds. The current context coincides with the disruption of the psychoanalytic institution which had steadily risen from its foundation. Helped by the trauma of World War I to become ascendent and reach its apogee in the last third of the 20^th century, the field has found itself in an ongoing downward trajectory, struggling to prove its relevance (Prince, 1999, 2005) and confront its relationship to issues of race and gender that have pushed forward partly in reaction to Trumpism.

We do know that threat and trauma produce rigidity and a tendency toward a regression from complexity to concrete thinking that depends on binary categories. At a time when old certainties are undermined by social chaos, can the institution of psychoanalysis resist simplification? On the psychoanalytic right, there is a strong inclination to resist the intrusion of the external world and restrict psychoanalysis to its traditions. On the left, there is as strong a reaction to the traditional, a condemnation of the perceived location of psychoanalysis within a racist, misogynistic, and homophobic power structure with a call to extend psychoanalysis in the direction of social goals.

While the extreme right is characterized by the exaltation of a glorified, mythic past that never existed (Snyder, 2018), there is also a powerful tendency on the left to devalue the past, simultaneously exploding both idealizations and legitimate accomplishments. While the currently politicized field of contemporary psychoanalysis is a potentially vital resource for this particular time, it is also a characteristic of human nature to become rigid in reaction to trauma with increasing intolerance to others. To counter such rigidification, Vamik Volkan (2019), for example, “urges that large-group psychology in its own right becomes a required course in psychoanalytic training institutions” (p. 153).

While it is crucial for psychoanalysis to be sensitive to social injustice, and for trauma as real to be central to psychoanalytic concern, there are problems associated with the new “wokeness” fueled as it is by an admirable commitment to social justice. While its moral certitude is understandable as an antidote to a plague of doubt engendered by our current social world, its rejection of the authority and expertise of the past also severely limits its usefulness. As the gross evils of misogyny, homophobia, and racism command redress, it is not constructive to reduce our history entirely to these traits. Though there is reasonable evidence for these in our history, and we have much to learn from them, there is also a strong case to be made for the legacy of psychoanalytic contributions to the healing of wounds wrought by these traits. Having advocated for the centrality of culture, history, and diversity long before it was fashionable, I now find myself threatened by its ideological appropriation. There is a well-documented history of psychoanalysis turning on and extruding its own. Finding the Eriksonian concept of identity (Erikson, 1959) to be particularly productive though currently unfashionable, I find a mirror of “identity politics” in an “identity psychoanalysis,” and find both more than unhelpful. I have had a career-long concern about the countertransferential denial of the reality of victimization, but also concern about the iatrogenic encouragement of a victim mentality at the expense of support, for example, for resilience. Psychoanalysis has been at its best when it has been tolerant of thought and at its worst when it has curtailed irony and controversy. It is faced then with an unprecedented dilemma, moral authority being vital to mental health.

Jonathan Lear’s (1999) speculation that psychoanalysis might be necessary for a democracy raises a converse question: What are the external conditions necessary for psychoanalysis to function. Can there be a psychoanalysis without democracy, without the protection of the freedom to have free associations? Can an internal world be explored when surrounded by a confluence of trauma that force attention outward? Can there be a profession which has as its concern psychic reality exist when a pandemic of political and biological virus produces a moral panic and a declaration of war on external reality? Each specific treatment is conducted in the atmosphere provided by the profession as a whole.

The world of yesterday

To summarize, a confluence of upheavals—pandemic, politics, an epistemological crisis, pervasive distrust of expertise and evidence—constitutes a trauma and produces a new context for psychoanalytic work, so that it, parallel to the external world, has become defamiliarized if not, at sometimes unrecognizable. Nostalgia for the world as it had been is expressed by Stefan Zweig (1943) in his poignant description of the world he grew up in the World of Yesterday. His anticipatory elegy describes a world from which he seemed to be only temporarily exiled until he realized he would never be able to return because it no longer existed. The eager anticipation of vaccines and herd immunities elide a more sober appraisal that the virus we are experiencing, with its prolific and virulent mutations, can be contained but not eliminated, and that other environmental stressors and diseases may make the return to “normal” an improbable wish. A “new normal” needs to evolve.

Our clinical practice today is contextualized by a co-participant trauma. Multiple crises, a global pandemic, a plague of information technologies producing a pestilence of disinformation and a radical assault on the concept of reality, a radical upheaval springing from injustice and inequality the pervasiveness of which had been previously dissociated, all together in the shadow of technological transformation which herald unknown consequences, is irreversibly placing us into history. Previous transformative historical crises have coincided with psychoanalysis but as Runia (2007) has described, history requires time and a process to be “consumed” but these today are occurring far too rapidly and pervasively to consume. Goldman (2020) reflecting on the changes wrought by the pandemic and politics, writes that an old world is dying but a new one is having trouble being born.

Several of my patients have articulated a feeling of “why bother?” a phrase that is almost pathognomic of trauma. “Why bother” stems from hopelessness and defeat, the feeling that ones’ efforts are meaningless. It is giving up the hope for a benevolent authority to whom one can turn for some kind of guidance. Similarly, the pandemic psychoanalyst contending with challenges to basic assumptions and a treatment model that may be as hard to recognize as the contours of quotidian life, may struggle with their own search for meaning. However, the analyst is de facto charged as the custodian of the reasons to “bother.” While the modifications of the treatment model necessitated by the pandemic may not be initially recognizable as practice, they may actually represent a distillation of its essential ingredients. Previously, psychoanalysis was the bridge between the two inner separate worlds inhabited by patient and therapist. With today’s divide between past and future, patient and therapist find themselves together on a bridge between the old structures and the blueprints for new ones.

NOTE

1. Robert M. Prince, Ph. D., ABPP, is an Associate Editor of the American Journal of Psychoanalysis and a past president of Psychologist-Psychoanalyst Clinicians, Section V of the Division of Psychoanalysis of the American Psychological Association and formerly on the Board of Directors of the Division of Psychoanalysis and of the Academy of Psychoanalysis. He received his Ph.D. in clinical psychology from Columbia University and his Certificate in Psychoanalysis and Psychotherapy from the NYU Postdoctoral Program, where he is adjunct Associate Professor and past co-chair of the Interpersonal Track and one of the founding members of the Trauma Studies Specialization. Among his 40 publications are The Legacy of the Holocaust, The Death of Psychoanalysis, and edited special issues of the American Journal of Psychoanalysis: Trauma and Culture, and What is Effective in Psychoanalytic Psychotherapy: A Historical Reprise. His most recent articles reflect a concern with divining concrete historical actuality in the shadow of context, construction and narration.