The coronavirus epidemic, which was declared a “pandemic” by the World Health Organization on March 11, 2020 and is having a global impact, has affected all of our lives and has also had a major impact on the frame of psychotherapy. Even those skeptical of online work have had to switch to online psychotherapy due to the obligations of the epidemic on our daily lives and in order to maintain a safe work environment. Let us explore the frame of online psychotherapy with some sub points.
1) Environment of Uncertainty
The change in the working frame of psychotherapy and the shift to online work happened very abruptly. Changes experienced in psychotherapeutic work usually happen by noticing in advance as much as possible and by taking time to work on the change. In psychotherapy; holidays, change of payment, finalization of the therapy process and change of room and move are informed in advance and the connotations, feelings and thoughts created by this situation are explored and studied psychotherapeutically.
Certainty, clarity about what to do and how, are important to ensure a sense of “stability” and not being shaken. The environment of uncertainty imposed by the outside world due to the coronavirus epidemic has resulted in the psychotherapist’s inability to maintain stability and certainty of frame. Both the psychotherapist and the client are trapped in the same uncertain external world. Questions such as “when, what will happen, how long will it last, when will it end” cannot be answered. Due to this sudden emergence and unanswered questions, there is no clear advice for the process of uncertainty yet. How this process is experienced, and the clarification of the answers will be possible in the future. What defines the “now” is “experimentation.” Experimenting, trying to adapt…
2) Being Safe: Change at a Safe Working Distance
One of the most important features that the psychotherapy frame should offer is the state of “being safe”. The psychotherapy frame offers some conditions for the safe conduct of the psychotherapeutic relationship and the psychotherapeutic work: It is important that the psychotherapist can perform the psychotherapeutic work freely and without fear, thanks to the limited duration of the sessions, the performance of the sessions in a certain period of time, the prohibition of touching, the prohibition of developing a relationship other than the therapeutic relationship, the work is performed only to meet the psychological needs of the client, and the frame rules protect the psychotherapist as well. Due to the coronavirus epidemic, it does not seem possible to work safely in a physical environment that is contagious, including airborne particles, and where there is a possibility of becoming infected and ill. In the days of the coronavirus epidemic, when being together in a physically enclosed space poses a risk to one’s own health and to the infection of others, the safest psychotherapeutic work setting is to not physically come together and to continue psychotherapeutic work without physically being together. The development of technology and its strong integration into our lives provide various ways to continue psychotherapeutic work without physically coming together. With the help of online platforms it is possible for us to reach each other with our voice and image.
3) Online platforms
In cases where the internet is not available and you do not feel ready for an online session, you can use phone calls. Applications like Skype, WhatsApp video chat, Facetime, Zoom, Whereby, Google Duo, Google Hangout can be used to connect with both video and audio. Different versions of these applications can be found on the internet. It is important to find a platform that can be shared and turned it into an online meeting space where the boundaries of the psychotherapeutic setting are protected during the session.
4) Maintaining the Psychotherapeutic Frame in the Online Session Room
- Confidentiality: Confidentiality and privacy in psychotherapy are very valuable to allow free association, i.e. to say what comes to mind, preferably without censorship, and to create a safe working environment. While ensuring the element of confidentiality in physical conversations is the responsibility of the psychotherapist, this time this responsibility belongs to both parties, as the psychotherapist and the client create their own physical spaces when working online. To ensure the confidentiality of the psychotherapy session, it is essential that no one else is in the space the client is using for the online session, that no one else / a third person is listening or witnessing the session. In addition, sessions should not be audio or video recorded.
- Abstinence: the principle of abstinence is important in psychotherapy, and this principle is emphasized even more in psychoanalytic psychotherapies. In the session room, feelings of satisfaction and contentment are not conveyed with their concrete and physical meanings, but the feeling of abstinence that arises from not being satisfied is put into words and presented, and psychotherapeutic work is practiced. Following the principle of abstinence, where psychotherapist and client are physically in the same room, in online sessions where it is not possible to be in the same room, one should not eat or drink, smoke or come to the session with alcohol and follow the rules in the room.
- No Stimuli: The meeting room created online must be free of possible stimuli. Outside noise should be kept to a minimum, and other stimuli that might intrude into the room, such as phone calls, emails, and other notifications, should be blocked during the session because the online conversation is taking place through a device. External conditions that interfere with free association and immersion should be reduced as much as possible. The constant interruption of attention by an external stimulus makes it difficult to focus on the inner world.
- Other conditions of Online Psychotherapeutic Framework: During the session, the client calls the psychotherapist through the pre-arranged online platform. As with physical calls, even if the client calls late, the psychotherapist is informed at the end time that the session is over, and the client exits the online conversation via the end button.
According to the online working conditions offered by American Psychoanalytical Association, you should sit in a place that allows the session to be set up. If possible, a device should be set up that is not held in the hand. Lying in bed or any other place, sitting on the floor, or walking around the room should be avoided (this does not include physical interviews where the patient is lying on the sofa and the psychoanalyst is sitting behind the sofa in a position that the patient cannot see. Online psychoanalysis interviews take place with the patient lying on a sofa-like chair and the camera turned off). As in the physical meeting room, there can be a napkin handy next to the seat. An appropriate dress code should be followed for the meeting in the physical room in front of the screen. Take fifteen minutes before and after meetings at American Psychoanalytical Association to focus on the meeting and to internalize, and reflect on it. Efficiency will be increased if you haven’t left another online meeting or face to face meeting right before the session and not start another online meeting or face to face meeting right after the session. Space is also one of the factors that should be considered. Ensuring that the online meeting is connected from the same place/room where the physical meetings are held, if possible in a fixed room, will increase the efficiency of the meetings. It may not be easy to pay attention to this, but it is undoubtedly beneficial.
5) Loss and Grief
The coronavirus epidemic has caused many losses in our daily lives, increased the risk of losing loved ones, and some losses have occurred. We go through days that can be quite traumatic. Freud says that psychoanalytic study is essentially the study of loss and grief. As we lost the physical world, our losses increased. When we look at the frame of psychotherapy, especially when we think of ongoing psychotherapeutic work, the physical dimension of the therapist and the client has been lost, and very suddenly. The loss of the physical connection has occurred. Physicality includes all the physical elements and bonds, such as the presence of the therapist in the room, being with the therapist in the same room, the meeting room where one usually stays, and the way one comes and goes in the meeting room. For those who have just begun or will begin psychotherapy, the opportunity to be in the same room with a psychotherapist is lost, at least for now. Nowadays, part of the work of psychotherapy is the losses and to grieve for what has been lost.
6) Loss of Domain and New Representations
We need not consider the loss of the bodily domain as a negative and undesirable element in online work. While psychoanalytic psychotherapy work has already been deprived of many domains in the enactment of unconscious representations, the forced online work deprives us of some aspects of corporeality. The loss of domain offers the possibility of awakening further unconscious associations and forming new representations. In psychoanalysis, for example, the psychoanalyst is not visible to the patient; the loss of visuality allows the psychoanalyst to project more intense representations from the inner world. In psychotherapy, the loss of the bodily bond also prepares the ground for the revival of new representations.
Wishing you healthy days.
Clinical Psychologist & Psychotherapist & Psychoanalyst in Formation IPA
Deniz Coşan is a Clinical Psychologist & Counselling Psychologist & Psychotherapist & Psychoanalyst in Formation located in Istanbul, Turkey. She applies counselling, psychotherapy and psychoanalysis for adults in private practice. Her sessions are both in English and in Turkish, face to face & online.