Reflections on the role of the analytic setting in the light of COVID‐19 - Wiley

Abstract

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There have been many reflections, both individual and collective within our Institutes, on the effects on our work with patients caused by COVID-19 and the requirement to move suddenly from the setting of our own consulting rooms to working with patients online (see also, the previous issue of this Journal). This paper focuses on what we have learned from these experiences that can add to our knowledge about the role of the setting in analytic work. Drawing on Bleger’s (1967) seminal paper highlighting the usual setting as a mute projection carrier for primitive wishes and affects, the paper explores how different patients have reacted to the loss of the analyst as the guardian of the setting and in particular as an embodied presence. Some key questions and challenges for both patients and analysts during the pandemic, when ‘the setting begins to weep’, are explored.

Introduction

Over the past few months, as I was preparing this paper for a public lecture for the West Midlands Institute for Psychotherapy, thinking that COVID-19 would be well behind us, little did I know that today, the pandemic would be far from over and at the time of writing, many of us are deciding only now, together with our patients and supervisees, when and how we should return to our consulting rooms. I had hoped to be back in the privacy and familiarity of my own consulting room with a recovered space for reflection about the effects on my patients and me of more than 14 months working online. But no such luck, though I am now thinking about it. For this reason, this paper remains work-in-progress with ideas that are tentative and reflect my own views.

Gampel (2020, pp. 1223–24) reminds us that when social trauma is present in daily life, both patients and analysts share the experiences, and this makes it difficult to be able to think about the events as they are happening. She quotes Appelfeld (1998), talking about the Shoah: ‘it is not possible to look directly into the sun’ (Gampel, 2020, p. 1224). I think it is for this reason that writing this paper at this time, has been quite a challenge.

Some of you may have heard the recent moving interview on the UK ITV News with the Indian journalist, Barkha Dutt, reporting tearfully about the lack of access to medical care and funeral facilities for Indian people, when in the moment of her grief after her own father had just died of COVID. Gampel ends her paper, albeit not about the effects of the virus, but with a statement that is pertinent with strong echoes of our present situation:

events leave profound marks on individual and collective histories … their meaning and effect are felt at different times. A ‘before’ and ‘after’ are configured around the events. And now we are simultaneously in an everyday before and after, and in a threatening and painful ‘today’ that has no end.

Being an analyst

Before embarking on an exploration of the effects on our practice of a major change in the setting of our work, I want first to set the scene by saying a little about what for me is of the essence in my identity as an analyst in practice. I think this will help us to frame some COVID-related thoughts about the nature and significance of the setting generally and about the online setting in which we have all been forced to work. Of course, it is not always easy to convey in words the essence of what we do, so let me begin by drawing on a powerful personal experience that leaves a strong sense impression.

I have owned a house in the south east of France for more than 20 years. It is not too far from Avignon. When I am there, I visit a wonderful old church in Uzės. I sit in one of the pews, drinking in the atmosphere, the sounds, the smells and listening to the music when the old organ housed there is being played. I am immediately in a very particular state of being. The nearest I can come to describing this presence is that it is embodied but also profoundly spiritual in the sense that it acknowledges something bigger than me. The church has a significant history. It is a former Roman Catholic Church, neo-classical 17^th century in style, that was gutted during the French Revolution, and later rebuilt. It replaced a still earlier cathedral destroyed in the 12^th century during the Albigensian Crusade. It has a campanile and a well-known Tour Fenestrelle, the only part to survive from the Medieval structure. I am not religious, but the sense of awe, sitting there quietly, attending simultaneously to my environment with its history and my inner experience, is not so far away from the state of being I hope to find when I am with my patients, listening to them while at the same time, listening to myself.

A friend told me of a similar experience after a big orchestral Promenade Concert in the London Albert Hall. She returned shortly after the end of the concert to pick up an umbrella she had mistakenly left under her seat. Even in the huge, empty hall, she felt the resonance of the music, the orchestra, the audience and the place; a momentous sense experience she had absorbed and that would endure.

It is this I am talking about when I try to convey what is important to me as an analyst. Jung comes near to it with his ideas about unconscious identity: that what we do involves a relationship between two external and internal worlds with the potential to make something in depth that is bigger than both of us. For the analytic relationship to deepen and to practice competently as an analyst, we need an internal setting that guides us.

Michael Parsons in his book Living Psychoanalysis (2014, p. 150) remarks that ‘the analytic process feels at once familiar and a mystery’. He quotes (Parsons, p. 160) a piece of writing about the craft of poetry written by the poet Seamus Heaney:

Technique as I would define it, involves not only a poet’s way with words, his management of metre, rhythm, and verbal texture; it involves also a definition of his stance towards life, a definition of his own reality. It involves a discovery of ways to go out of his normal cognitive bounds and raid the inarticulate: a dynamic alertness that mediates between the origins of feeling in memory and experience.

I like very much this phrase ‘raiding the inarticulate’ as for me, it succeeds in capturing the essence of analytic identity and what we do with our patients. However, to raid the inarticulate, we need to be secure in terms of our own internal setting. How, I wonder, has the move to online work to escape the real and shared dangers of the pandemic, affected analysts’ internal settings, the home of their analytic attitudes? How has the change of frame, imposed on us all, affected both patients and analysts, and how is it affecting our openness to ongoing unconscious processes?

Parsons develops his idea of an internal setting:

just as the external setting defines and protects a spatio-temporal arena in which patient and analyst can conduct the work of analysis, so the internal setting defines and protects an area of the analyst’s mind where whatever happens, including what happens to the external setting, can be considered from a psychoanalytic viewpoint … the internal setting constitutes a psychic space which is correspondingly protected (as is the external setting) so that within it, analysts can maintain their own psychoanalytic reality.

His words ‘protected’ and ‘psychic space’, are key here. In my day-to-day work, I see myself as the guardian of the frame or external setting, hopefully with the agreement of my patients, and this constitutes a protective environment for analysis. It sets the scene for the internal work that is dependent on finding a psychic space for which my internal setting, developing all the time, can serve me well enough.

A central question to be asked from this is, what has happened to the protective environment and the role of the analyst as guardian of the setting during the pandemic, and how has it affected the internal setting of the analyst and the psychic space we need for our work? What, we may ask, do patients project into the online setting?

More than a year of COVID-19

In March 2020, because of COVID, we all had to scramble suddenly to manage technologically-mediated treatment. We had no choice, and I guess it has been better than nothing. For some colleagues who ventured back into their consulting rooms after the first lockdown, they had to withdraw once again during a second one.

Gillian Isaacs Russell summarizes the situation with power and clarity: ‘the uncharted waters of the pandemic … brought loss of routine, environment, life as we have known it … all threatened with helplessness, loss, with death … online we sometimes feel alone in the absence of another’ (2020, pp. 366–67).

Modifying her last thought a little, working online feels for me as if I am in the presence of an absence, and I agree with Isaacs Russell (ibid., p. 368), when she describes telepresence as an illusion of presence. They are not the same thing. To be fully present, there is a need for bodies in the room together.

Thinking about the use of technology in general, Isaacs Russell reminds us that, ‘the nature of technology encourages a kind of distraction called ‘continuous partial attention’, a state when we are hyper-vigilant, anticipating potential connection, always on anywhere: when we are so accessible, we are inaccessible in the here and now’ (Isaacs Russell 2020, p. 368). This seems a far cry from the kind of attentive listening we need if we are to be able to raid the inarticulate, picking up unconscious communications through the somatic countertransference.

I do not wish to dwell for long on the effects of extended online work, as we are all familiar with these. Exhaustion, loss of privacy and confidentiality; what The Guardian (Sarner, 14 April 2021), described as ‘brain fog’. We are constantly managing digital unreliability, poor quality sound and vision, interruptions, and sometimes uncomfortably locked periods of eye contact. There are many examples of what Alessandra Lemma (2017, p. 105) calls ‘Skype slippage’, on the part of both patients and analysts, where looser boundaries, inappropriate settings and the emergence of an animal kingdom appearing online during sessions all serve to affect security and confidentiality. As one supervisee said to me, I have never seen so many cats’ tails on screen before! A major concern could be that we have all got used to it, making the necessary adaptations, but at what cost?

We have lost the essential transitions at the beginning and ends of sessions: the journey to the analyst’s consulting room when the session begins and the journey home afterwards. As one of my supervisees put it, patients have lost their decompression chamber. Instead, we have sudden beginnings and endings that often feel like ruptures. Using the analogy of a mother feeding her baby, there is no space for settling in or communicating before feeding; neither the gentle holding and relating prior to putting down afterwards. One of my patients used to mark the significance of her journeys to and from my consulting room by taking a series of photographs through the seasons. She told me she looks at these from time to time to remind herself of what she had that now feels so remote.

There are questions as to why and how analysts have chosen to use the telephone, or Skype or Zoom. How much have patients been involved in these choices about which setting might best facilitate imagination? There are decisions to be made too about who contacts whom with invitations to connect and the rationale for this.

Most of my patients have sessions at least twice a week and sometimes three or four times a week. Nearly all of them use the couch. With all of them, we agreed to work on either Zoom or Skype. I have left them to work out how best to organize the setting in their homes or offices. I observed that all chose to replicate as nearly as possible the setting of my consulting room, lying down on their own couches.

The partner of one of my supervisees moved to France for work, leaving my supervisee with some agonizing decisions about where he would live, the difficulties of travelling back and forth during a pandemic and how to manage to contain his training patients. We had a lengthy discussion as to whether he would tell his patients when he was in France and when in the UK, but decided that on balance, it would be in the best interests of his patients not to, and to offer continuity and containment rather by using a background photograph of his London-based consulting room while he was in France. I think this was actually a good decision, but it is in a way fake, not authentic, and not helped by the pixilated edges to his form and presence on the screen.

Money is unique in analysis since it is both part of the frame and part of the process. I have always tried to keep the exchange of money with my patients in the consulting room, hanging on – in the face of online banking – to what might be thought of as the old-fashioned use of cheques and handing my patients an invoice in person at the beginning of sessions each month. Sadly, COVID-19 has meant that I have had to relinquish my preferred practice in favour of the more distanced online bills and payments.

Churcher reminds us how we underestimate the lack of privacy when telecommunications are introduced into analysis, emphasizing that ‘we need to be curious about what may be deposited silently into the telecommunication’s system itself’ (Churcher 2017, p. 37). I will say more about this later. He makes a powerful point about privacy in general and its effects for us when working online:

while we retain our common-sense ability to judge if the roof (or our room) is leaking, or if the walls are permeable to sound, we generally cannot tell whether our phone has been converted into an eavesdropping device or our emails or Skype conversations are being intercepted. There is too much to know about the digital world and not enough common-sense to guide us through it.

Frame or setting?

Questions arise as to whether to use the term ‘frame’ or ‘setting’? Some authors use the terms interchangeably; others see them as nuanced and different.

Definitions from the Oxford English Dictionary of the word frame include:

1. a border that surrounds and supports a picture or door or window
2. a structure that holds together a pair of glasses
3. the basic structure of a building, vehicle, or piece of furniture.

The word framework is used to describe a structure made of parts joined to form a frame; one designed to enclose or support … to make ready for use.

Setting is defined as:

1. the manner or position in which something is set, fixed, or placed
2. the manner in which a stone or gem is set or mounted
3. a person or thing’s immediate environment or surroundings
4. a place or time in or at which a story, play, scene is represented as happening
5. the manner in which a poem or form of words is set to music.

Marion Millner prefers the term frame, referencing the frame of a painting:

in order to understand more about the meaning of the word illusion, I found it useful to consider its role in a work of art. I had already, when trying to study some of the psychological factors which facilitate or impede the painting of pictures, become interested in the part played by the frame. The frame marks off the different kind of reality that is within it from that which is outside it; but a temporal, spatial frame also marks off the special kind of reality of an analytic session. And in psychoanalysis, it is the existence of this frame that makes possible the full development of that creative illusion that analysts call the transference.

Although a frame can be seen as rather rigid, it carries the sense of something containing and protective and of course different frames are likely to set off what lies within in different ways.

Cooper uses the word setting: ‘the setting is a location of dynamic transit between the vital, interactive elements of containment and interpretation of the patient’s conscious and unconscious experience’ (Cooper 2019, p. 1440). Following Winnicott he says, ‘the setting operates as an auxiliary function for the analyst’s capacities, which include containment, interpretation, and as a “participant” and supervisor of play’ (ibid., p. 1440).

Other authors too prefer the term setting (Davies 2015; Churcher 2005, 2016, 2017; Perelberg 2021; O’Neill 2015; Lemma 2014), and I shall, from here on, also use the term setting as I think it takes us more helpfully to the physical setting of analysis and the formal arrangements put in place so that we can differentiate between analysis online and analysis in person.

Exploring what Jung has to say about the setting, I found no references to either of the terms frame or setting in the Index for Jung’s Collected Works. However, Jung does make a significant contribution to our theme with his concept of the vas bene clausum. He defines it as:

and later:

the motif of the vessel is itself an archetypal image which has a certain purpose … a vessel is an instrument for containing things. It contains for instance liquids and prevents them from getting dispersed … this idea of a receptacle is an archetypal idea. You find it everywhere and it is one of the central motifs of unconscious pictures. It is the idea of the magic circle which is drawn round something that has to be prevented from escaping or protected against hostile influences.

I like the idea of a magic circle as marking out the temenos or sacred precinct of something that is special. Jung gives us examples of the magic circle in action. For example, as a way of keeping the devil out when digging for treasure or when, once there is a city plan in place, there is a ritual walk to mark out what will be inside the city limits. He tells us too that in some Swiss villages, the priest and the town council ride around the fields as a ritual blessing to protect the harvest (Jung 1935, para. 409).

I found two other papers written by Jungian analysts on this theme. Gus Cwik’s (2010) paper called ‘From frame through holding to container’ discusses the related terms frame, holding and the container, showing how an emphasis on each will vary, depending on the needs of the patient.

Betsy Cohen criticises psychoanalysts as having too strict ‘rules’ about the frame, of the view that original conceptions of the frame are ‘at odds with the current conceptualized principle of intersubjectivity; the field between the patient and the therapist that is co-constructed mutually’ (Cohen 2017, p. 70). She gives examples of how a much looser frame (contact outside of sessions, flexible session times etc.) can be therapeutic for her patients. She makes the point that the traditional ‘rules’ provide an illusion of safety and security for both patient and analyst. From my own perspective, I think she underestimates the significant role of the frame as providing something so essential for the necessary internal work including analysing those patients who can hit against the frame. Reading her paper sent me back to Freud’s and Winnicott’s writing about the setting.

Freud, in his ‘Papers on Technique' (1912, pp. 123-34), defines the setting as made up of a set hour, the payment of fees, the use of the couch and the fundamental rule of free association. Winnicott, paraphrasing Freud in his own inimitable style, describes the frame as involving:

1. Meeting at a stated time daily, meeting five or six times a week.
2. The analyst being reliably there, on time, alive, breathing.
3. The analyst staying awake and pre-occupied with the patient.
4. Love expressed through positive interest and hate in the strict start and ending times and the matter of fees.
5. As a central aim, to understand the patient.
6. A method of objective observation.
7. This work to be done in a room, not a passage; a room that was quiet and not liable to sudden unpredictable sounds, yet not dead quiet and not free from ordinary house noises. This room would be lit properly, but not by a light staring in the face, and not by a variable light. The room would certainly not be dark, and it would be comfortably warm. The patient would be lying on a couch, that is to say, comfortable, and probably a rug and some water would be available.
8. Moral judgement is kept out of the relationship … naturally if there is a war or an earthquake or if the King dies, the analyst is not unaware.
9. The analyst as more reliable than people in ordinary life; punctual, free from temper tantrums, free from compulsive falling in love etc.
10. There is a very clear distinction in the analysis between fact and fantasy so that the analyst is not hurt by an aggressive dream.
11. An absence of the talion reaction can be counted on.

12. The analyst survives.

    (Winnicott 1958, p. 285)

It seems to me that although the significance of the analytic relationship has changed a great deal since Freud’s time, not much has changed in the way we organize the setting for our work even if some Jungians may have a different attitude to the use of the couch. I was amused by Winnicott’s description in point 7 of the care needed in terms of setting up our consulting rooms, especially, in the context of working online. I was struck too in the light of COVID, by his last comment in point 12 that the analyst needs to survive!

The mute setting that begins to weep

For some years now, I return often to a seminal paper written in 1967 by José Bleger, an Argentinian psychoanalyst. Bleger’s work has been translated into English by John Churcher and Leopoldo Bleger (2013). They too use the term setting as the best translation of the Spanish word used by Bleger, encaudre.

Bleger makes a distinction between the analytic process and what he calls non-process. Non-process is a set of constants; what we might think of as the setting. Generally, the analyst is the guardian of the setting. This includes all the things already referred to such as session times, fees, holidays, the room etc. This set of constants allows a process to go on within it. Bleger’s main point is that the setting itself can function like an invisible phantom limb, in that we only become aware of it when it is disrupted. Bleger puts forward the idea that patients project into this normally mute setting, early primitive symbiotic feelings connected with the mother. Bleger thinks that what is projected may be considered as the psychotic parts of the personality we all have and includes our wishes for fusion and regression. He considers that the most persistent, tenacious and unnoticeable ‘bastion’ can be deposited in the setting:

the setting is maintained and tends to be maintained (actively by the psychoanalyst) as invariable. As long as it exists in this way, it seems to be non-existent or not to count, like institutions or relationships that we only take notice of precisely when they are missing or obstructed or come to an end.

(Bleger 2013, p. 230)

The setting then remains mute until it is disrupted when it may begin to weep or cry. Bleger again:

in sum, we may say that the patient’s setting is his most primitive fusion with the mother’s body and the psychoanalyst’s setting must serve to re-establish the original symbiosis, but only in order to change it’.

(ibid., p. 240)

In a previous paper of mine (Wiener 2015), I quoted two clinical examples from my own practice relevant to Bleger’s ideas. I had to change a session time for a patient on a permanent basis. She had a furious reaction that took months for us to work through. She suffered a neglectful and abusive childhood and her wish for reliability and containment was projected into the mute setting where she appreciated the unchanging aspects of session times, my room and indeed my embodied presence. It was only when there was a rupture in the otherwise normal setting that we could both come to see after a period of great turmoil, that my request to change her session time had repeated an experience of a cruel mother who so frequently abandoned her to manage on her own.

Another male patient was severely disturbed by the appearance of two re-upholstered chairs in my consulting room. His parents divorced when he was young and his father, with whom he lived, acquired a new wife. It was as though the strange smell and feel of the new chairs activated both the loss of his mother’s body and the new and strange smells of his stepmother.

Lemma draws on Bleger’s ideas to extend the setting to include the analyst’s body and how patients can ‘relate to the analyst’s body as an invariant part of the setting as if it were part of the background and silent’ (Lemma 2014, p. 226). She gives as an example a time when she wore a new, bright blue shirt and cut her long hair and how this upset a female patient whose mother had died young and who had long hair with great meaning for the patient: ‘exposure to the separation between us, as triggered by my altered appearance, was felt by her to intrude into the symbiosis, that is, as an act of aggression towards her’ (ibid., p. 238). Lemma stresses the key role of the somatic countertransference in revealing to the analyst the role of the setting for her patients, especially when there are unconscious attempts to intrude or control.

Key clinical questions

The sudden and unexpected change in the setting of our work triggered by the dangers of the pandemic meant that the setting in which we work was no longer mute. It began to weep and, sometimes, it was actively crying.

Question: What have our patients been projecting into an online setting. Has it had different effects on our patients and indeed on us, the analysts? Among my patients, I have been able to observe three distinctly different reactions in terms of what is projected into the online setting. I will give you some brief case vignettes later in the paper:

1. Those for whom the change in setting has led to suffering, grief, failures in sustaining a memory trace and sense experience of past meetings in person. They feel uncontained and long for the return to meeting in-person where the analyst may become, once again, the guardian of the setting.
2. Those patients who need to defend themselves against the change of setting using control or attack as the fears of the emergence into consciousness of Bleger’s primitive wishes for a symbiotic relationship with mother are too frightening and must be hidden. They make themselves unreachable in different ways.
3. Those where there has been a ‘good enough’ adaptation to make the best of the online setting and where patients take an active part in looking after the setting with an acknowledgment that the trauma of the of the pandemic is shared by us both. In a well-established analysis, it can be possible for the setting to remain alive in the minds of both patient and analyst. There can be presence, even in the absence of two bodies in the same place (Perelberg 2021). I think too that for some patients, especially those with intrusive or narcissistic parents, the experience of working through the screen of a laptop, computer or even the telephone, serves to provide a safer setting in which to talk about sensitive matters previously inaccessible face-to-face.

Question: The analyst is no longer the sole guardian of the setting; it is a shared activity, welcomed by some patients and hated by others depending on their personal histories and their relationship with me. What is the meaning of a shared responsibility for the setting? Isaacs Russell notes that ‘the very introduction of technology abrogates analytic responsibility for the setting … it is unreasonable to expect patients to provide a safe setting for themselves’ (2020, p. 370). I think this is the case for some patients, but in others the requirement for shared care of the setting has led to some of my patients feeling closer to me.

Question: Do analysts vary in their capacities to adjust to working online?

I have been open in this paper that my internal setting, including my somatic countertransference, has been compromised over the long time away from my consulting room to the extent that I have sometimes wondered what on earth I have to offer. I recognize that this may not be the case for other analysts.

Question: For those of us that have worked with patients whom we have come to know well before moving online, to what extent does the memory of an embodied presence in the room transfer online and sustain us in our efforts to manage telepresence? Isaacs Russell wonders if memory enlivens and permits greater imagination. My experiences and tiredness suggest that the memory of an embodied experience can easily fade.

Question: Does the frequency of sessions and related to this, the use of the couch in analysis make a difference to both patients’ and analysts’ capacity to adapt to telepresence? Can patients regress when there is telepresence?

Question: What actually happens to our somatic countertransference without two bodies in the room?

Clinical vignettes

Here are some case vignettes of patients, where working online has been very challenging and others where the online experience could be said to have been more challenging for me than for them. At the time of writing, all my patients have been in analysis for some years and I have not begun during this period with any new patients online.

Joanna

I have worked with Joanna for more than 10 years, three times a week. She is intelligent, insightful, and involved in her analysis. For her, analysis has been a lifesaver. Both her father and brother are bi-polar, and her mother has long-term chronic depression. She has both manic and depressive episodes (somewhat better now) and has recently been put on a new medication to stabilize her moods. She has huge courage and holds down a good job and has a long-term partner. She worries about weekend and holiday breaks and frequently acts out in the breaks, sometimes causing both of us concern. For our Skype sessions she uses a sofa in a room in her flat, taking care to look after the setting as much as she can. She is the patient who takes photographs for all seasons on her way to and from my consulting room.

She needs me to be a firm container and often comments that I have always been reliably there for her, unlike some of her friends who have been frequently let down by their analysts in different ways. I observe that in sessions she always covers herself up with a blanket and her much-loved dog is lying at the bottom of her sofa – usually invisible to me. I have come to think that, as a response to the enforced setting, Joanna has developed a second skin (Bick 1968), a protective covering she must find for herself to try and bind together the most primitive parts of her personality without my bodily presence in the room with her. She cannot regress safely without me there and longs to return.

Tania

Tania is a relatively new patient I have seen for about three years. Just prior to lockdown, she had contacted her birth mother whom she had never known, and they had met. She is adopted and knows little about the first three months of her life. She was brought up in a high-achieving family but had a distant relationship with her mother who worked while bringing up four children. Tania was gradually learning the language of feeling and beginning to develop a reflective capacity, aware of her tendency to shut down, experiences that were not yet within her control. The sudden move to online work came at a delicate time in her therapy and was really unfortunate.

Tania is very competent and well-organized in all that she does, so initially she organized a setting at home for herself, using her own couch in a spare bedroom. It was as if, as with everything else, she took it in all in her stride without making a fuss or complaining. She is used to taking care of others and living with her own needs projected into others. The therapy carried on but felt for a while as if we had taken a backward step.

Two events happened around the same time and it was then that the setting began to weep. First of all, her husband walked into a session just as she was saying how difficult she found it to mention her feelings to him and how unavailable he felt. At the following session, she said she wanted to sit up as she wanted me to be fully present. She had been reading papers about boundary violations for a seminar. She then told me that some days earlier, I had inadvertently included her in an email that was not meant for her. I had no idea this had happened, and it was of course a minor boundary violation. But for her, it had a big impact. It was meant for my singing teacher and had some music as an attachment. She realized that I had a life outside of our sessions and this had an emotional impact on her. At this time, we were just moving from two to three sessions per week. After the Easter break, Tania could tell me for the first time how uncontained she felt working online. It was as if the distance she was experiencing from me put us both in touch with the first three months of her life spent in an institution with no special care. It is clear she needs to come back into my consulting room where I may again be available to offer the containment she needs.

Flora

I have seen Flora for a number of years, initially twice a week and now once a week. She uses the couch. In March 2020, we met in my consulting room to make arrangements to move online so that she could bid a temporary farewell to my room and its atmosphere when we were both present in person. I think I was more concerned about the move than she was. We began to work via Skype and she would use her own couch, sometimes a chair too. Often, she would be drinking coffee during our sessions. There was some Skype slippage: windows were open with lots of traffic noise making it difficult to hear her; trips to her kitchen in the middle of sessions to get water etc; moving around the room. I observed that she was rather casual as a co-guardian of the setting. Because of lockdown, she had to cancel a planned holiday abroad and when we met for our session, I was surprised to see her elsewhere in the house of friends. There had been no discussion about this in advance and it was probably against government guidelines at that time anyway. She was sitting at a kitchen table with her laptop in front of her. I was aware of a lapse in my concentration. Was I annoyed with her? My attempts at attentive listening were further compromised when I saw a man come into the kitchen. She realized too and said immediately, ‘I am going somewhere else’. I was aware of her climbing stairs with her laptop and going into an upstairs bedroom. She sat down on a chair and I was immediately faced with a large, unmade double bed behind her. Shortly afterwards, a dog came into the room and jumped onto the bed. Any possibility of raiding the inarticulate seemed remote. It was for me that the setting began to weep. She on the other hand seemed unaffected. After some reflection, I said to her, ‘Flora, I am not sure it is possible to work together today like this’. She was very startled, felt criticised and became defensive, apologizing as if she felt she had upset me. I wondered if I had acted out.

At our next session, back in her home, she brought a dream about a phone session with me where we were not getting on well. She told me afterwards that she thought I had spoiled her time with her friends and that I did not appreciate that this was her first time with other people and felt for her like some kind of holiday where she could socialize, rather than being on her own at home. I became the spoiling mother, like her own mother from whom she is estranged and who will not return her calls. We could both then begin to reflect on the role of the setting for her and she revealed that for her, working each from our own homes felt more friendly and equal and she preferred it. This included a fantasy that we could go on holiday together.

I am one of those analysts where my internal setting/internal analytic framework is compromised by working online. Neither my concentration nor my reverie function very well. After this session with Flora, I had a powerful memory of how sensitive I had been in both my analyses to any small changes in the setting. I think I was probably one of Bleger’s patients who lodged/projected early and primitive affects into the setting. Hopefully, I have moved on from this position but there is still the memory trace, that was strongly activated when Flora decided to change her setting without warning. What I learned was that I need to maintain my own self-awareness and understanding and that my dream states, my inwardly-directed listening, and my somatic countertransference can all feel compromised by Skype slippage. It opened up too, the possibility to talk more about the role of the setting with Flora.

Thomas

I have seen Thomas for some years for analysis. On the couch in my own consulting room, I have sometimes experienced him as disembodied as if the only life is in his mind. He lies motionless during sessions and his only movements are to turn his head frequently to look at me. In the beginning I wondered if this was because he needed to check that I was there. Later, I thought that it was more of a defence against letting himself free associate and fantasize during sessions. He has a number of obsessional rituals to hold himself together. When we moved to using Zoom, I observed that there seemed to be no difference at all in his feelings and behaviour. The changed setting permitted sessions to continue in just the same way as in-person.

For me, the setting was beginning to weep, but not for him. I could see then how much he had always used the setting as a place of control to avoid experiences of grief and loss which would be terrifying. As a result, it was difficult to ‘play’ in analysis. For some reason, I had also colluded with his suggestion that he would send me a Zoom invitation for each session, when for other patients, it is me who sends the invitation.

Recently, Thomas brought a dream:

He is in a war zone, trying to hide from the enemy, trying hard not to be seen and caught out but secretly spying, trying to see what the enemy is up to. He feels anxious that he might be caught. In the second part of the dream, there are giants present and other larger-than-life, thin, lanky figures. Greta Thunberg, the Swedish activist, is in the dream and she is in danger of falling from a cliff. It is unclear as to whether the giants will be able to save her from falling to her death. Then the giants and the thin lanky figures begin to fight amongst themselves.

This dream enabled me to comment on his need to spy on me as his way of controlling and keeping secret from us both, his feelings of vulnerability, existential anxiety and a terror of being dropped. It brought to light memories from him of his parents’ divorce when he was seven and how he thought everyone was going to die. I remembered my experience of Thomas lying on my couch, as if disconnected from his body but looking at me constantly. I realized then that this is surely his need to make sure I am there to catch him in case he falls.

Conclusions

One of the benefits of having to work online is that it has helped us to understand, in a more nuanced way, the role of the setting in analysis and indeed about its flexibility. All analysts will have had the opportunity to work with the ‘setting that weeps’ and take their reflections back into face-to-face analysis in their own consulting rooms, where the setting may previously have been mute and insufficiently considered.

I am clear from my research for this paper, and from my own experiences during this extraordinary year, that I want to be back in my consulting room as soon as it feels safe to do so. It is in the presence of my patients that I feel I can provide the most secure setting and within this to raid the inarticulate in the way that I need to as an analyst doing the best for her patients. To this end, I agree with Isaacs Russell’s words, albeit written before COVID:

We have been working in the presence of an absence. The absence of real bodies in the same room together confines us more to ‘states of mind’ than ‘states of being’ (ibid. 2015). It is an embodied state of being that truly allows us to communicate simultaneously with our patients and ourselves. However, I may have been guilty of selecting references in this paper that support my experience and my views, and I do recognize that some colleagues may be much more comfortable working online than I have been. For those living in countries where an analytic culture is only now evolving, the lack of trained analysts means that online analysis with overseas analysts is the only possibility. Nevertheless, Churcher’s words on the nature of the psychoanalytic setting continue to reverberate:

psychoanalysis is unique among human situations and tasks by virtue of its cultivation of curiosity about what has been deposited in the setting … in an analysis that is being conducted remotely … we need to be curious about the phantoms that silently take up residence in the body-schema of the patient, in that of the analyst and in the telecommunication system itself.

While each analyst can decide for themselves when and how they return, it remains the case that the setting of our profession may be forever changed by experiences of telepresence. Research in the field of information communication theory and technology wants us to believe of course that telepresence and presence are not so far apart (Isaacs Russell, 2015). Some of my patients are waiting impatiently to come back to my room, longing for the journeys to my consulting room that mark a transition to a different reality. They long for me to return to my role as the guardian of the setting that offers them the containment they need to play, to fantasize, and to relax into the unconscious. For these patients, the unreliability of the previously mute setting has helped both of us to become more aware of how the setting carries the primitive maternal function. For others, for whom it seems not to matter so much, I have learned more about their defences against intimacy and about their conscious and unconscious attempts to keep the setting mute. There have been some too, who have taken their role as co-guardian of the setting very seriously so that analysis can become truly relational as a shared experience.

I cannot end without suggesting, on a less personal note, that following COVID we have some obligations to consider our policies within our institutions. It is clear to me that online events have worked very well. They are more inclusive, drawing in larger audiences including people from other countries and creating a stimulating atmosphere where differences can be productively explored. It may or may not be important for our Societies that the profits from these events will be larger. The Society of Analytical Psychology’s recent online Child Conference, originally planned as a ‘live’ event to be held in Cambridge, drew in 220 people from 35 different countries. The event was exciting in terms of its content and its atmosphere, and we made much more money than we had anticipated from a ‘live’ event.

I am sure it is tempting too for many of our members to have all their committee meetings online; how much easier not to travel, to meet in the warmth of our homes. But at what cost? Surely, the need for states of being remains a crucial aspect of our reflective capacity when thinking together about all aspects of institutional life.

And what about our trainings? Here, I am more confident that trainees will meet in person again. It may only happen gradually, but trainees themselves are complaining and there is no substitute for the bonding that takes place in long trainings and all the informal communication that goes on in the spaces between seminars and other meetings. I would like to end with Isaacs Russell: ‘true presence, as unpredictable, spontaneous, and messy as it is, is irreplaceable’ (2020, p. 373). I could not agree more.

source: https://onlinelibrary.wiley.com/doi/full/10.1111/1468-5922.12717

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