The permanence of the setting modifications adopted during the covid-19 pandemic in the clinical practice of Italian psychoanalysts

The permanence of the setting modifications adopted during the covid-19 pandemic in the clinical practice
of Italian psychoanalysts

Daniela Cantone1, Stefania Cella1, Annarosa Cipriano1, Carmela Guerriera1

1Department of Psychology, University of Campania “Luigi Vanvitelli”, Caserta, Italy.

Summary. The research aims to verify if the remote modality, introduced widely by Italian psychoanalysts at the lockdown, remains in clinical practice today, with specific reasons and characteristics. The authors hypothesize that the use of such modality, beyond health limitations, is a point of no return compared to the classical setting. Based on this hypothesis, an ad hoc online questionnaire was proposed; the subjects were also called upon to express an opinion on taleanalysis. Two hundred sixty-seven subjects responded. The results confirm a wide use of remote analysis even in the current situation; they also seem to indicate recognition by psychoanalysts of the emergence of new psychic phenomena in this type of setting, for example, childhood traumas that in the face-to-face analysis were unknown or inelaborate, usable in the treatment process

Key words. Covid-19 pandemic, empirical research, post lockdown, setting, teleanalysis.

La permanenza delle modifiche di setting adottate durante la pandemia di covid-19 nella pratica clinica degli psicoanalisti italiani.

Riassunto. La ricerca intende verificare se l’uso della modalità da remoto, introdotto in maniera diffusa dagli psicoanalisti italiani al tempo del lockdown, permanga ancora oggi nella pratica clinica, con quali motivazioni e caratteristiche specifiche. Gli autori ipotizzano che il ricorso a tale modalità, aldilà delle limitazioni sanitarie, sia un punto di non ritorno rispetto al setting classico. Sulla base di questa ipotesi, è stato proposto un questionario online, costruito ad hoc; i soggetti erano chiamati anche a esprimere una opinione sulla teleanalisi. Hanno risposto 267 soggetti. I risultati confermano un ampio utilizzo dell’analisi da remoto anche nel post-pandemia; sembrano inoltre indicare il riconoscimento da parte degli psicoanalisti dell’emergere di nuovi fenomeni psichici in questo tipo di setting, per esempio traumi infantili che nell’analisi in presenza risultavano sconosciuti o inelaborabili, utilizzabili nel processo di cura.

Parole chiave. Pandemia di covid-19, post lockdown, ricerca empirica, setting, teleanalisi.

Introduction

Due to the covid-19 outbreak and healthcare restrictions (e.g., social distancing), psychoanalysts felt forced to use alternative settings than traditional face-to-face ones to promote continuity of care/analysis. As a result, teleanalysis, a remote psychoanalytic work, has spread worldwide using several modes of communication, such as phone, virtual communication devices, and videoconference1-5. Prior to covid-19, the online analytic settings (teleanalysis) were adopted under specific conditions inherent to the analytic couple: temporary relocation abroad, prolonged patient illness, patients with logistical (e.g., living in rural areas), clinical or social stigma difficulties that prevent access to mental health services in-person, non-native analysts speaker in the patient country, and training analysis for candidates in a country where it is difficult to find a training analyst2-4,6-9. The major psychoanalytic associations have responded to such practice by defining guidelines and recommendations for psychoanalysts doing teleanalysis10-13.

Online sessions used to be highly controversial. Thus, designing guidelines to address the developing area of distance-mediated treatment seemed to be a necessary response to analysts’ perplexities and negative stance arising from the risk of a potential alteration of the rigid psychoanalytic setting and analytical process14-17.

These are concrete aspects of both “setting-frame” and “setting-framework” that lead to specific dynamics, such as spatio-temporal ones, that – when altered – bring out intrapsychic phenomena with “strong paradigmatic value”18.

The rapid adjustment to teleanalysis due to covid-19 made it clear that the adoption of online analytic settings was already a practice widely used among analysts, albeit undeveloped theoretically and still immature from the theory of psychoanalytic technique standpoint, as a result of the fact that it was likely viewed as an exceptional situation, almost an anomaly5.

A large body of research has explored the relationship between psychoanalysis and teleanalysis, suggesting that this dimension of clinical work has also become a relevant issue in the task of contemporary psychoanalysis2,5,8,15,19-22. The remote setting forcing the absence of physical compresence emphasizes the relationship between the analytic method and the setting variations, primarily targeting what is “lost” and what is retained or even gained with such changes. François Richard23, arguing about the pandemic’s consequences, has outlined the analysts’ conflicting positions about the online working method. He stated that «remote analysis produces a trauma, due to sensory malnutrition and seduction in relation to the disruption of the usual rules»23. However, Richard continued by stating that «we can nevertheless estimate that analysis remains possible, the asymmetry does not disappear, and the perturbed distance induces serviceable effects23.

Although several studies support the effectiveness of teleanalysis, or point out its limitations, there is still «a lack of a metapsychological framework underlying such way of work that breaks into the analytic field»24.

The present study

In our previous study25, we aimed to explore to what extent Italian therapists with different theoretical-clinical orientations used videoconference psychotherapy to assess their satisfaction and opinion. We assumed that psychotherapists have a different perception of how to approach the therapeutic relationship in the remote setting and a different opinion on its quality based on the different therapeutic method of reference. Results suggested differences according to the therapists’ theoretical background. Specifically, psychoanalysts reported greater difficulties and fatigue using videoconference psychotherapy, although they recognized that it allows the continuity of treatment. Also, remote work limits the spontaneous breaks and the interpretation of the silences (here-and-now of the session or device’s technical problem). These difficulties might depend on the peculiar characteristics of the model (i.e., being non-receptive to the external stimuli and staying focused on the internal word playing in the analytic relationship). Based on these findings, the present study aims to examine whether psychoanalysts still adopt online analytic sessions and the motivations and characteristics of such practice. Moreover, we intended to explore the analysts’ opinion on the significance of the teleanalysis’ use two years apart from its introduction and beyond the emergency. We hypothesized that teleanalysis is still adopted by analysts, far beyond the need for health restriction (patients affected by covid, fiduciary isolation). Such setting variation is a turning point compared to the traditional face-to-face setting, also representing a significant alteration of the setting structure and functions, historically defined by the theoretical-clinical asset. Also, we suppose that, due to lockdown-related needs, teleanalysis is definitively one of the several modes of conducting analysis.

Methods

Participants and procedure

Participants were Italian analysts and psychotherapists with psychoanalytic orientation recruited through the psychoanalytic societies located in Italy. An informing email was sent to the mailing list of such societies or distributed by the Presidency/Secretariat among students and members. The only inclusion criterion was having adopted setting variations due to the covid-19 outbreak.

The mail provided a brief description of the study aims and a link for the web-based survey (SurveyMonkey). After providing informed consent, each participant was required to complete five sections of questions about remote work. Data were collected from the last decade of March to the first decade of May 2022. The study was approved by the Ethics Board of the Department of Psychology of the University of Campania “Luigi Vanvitelli” and conducted in accordance with the guidelines of the Declaration of Helsinki26.

Materials

Participants completed a questionnaire built ad hoc to evaluate the online sessions of analysis. The questionnaire was divided into five sections: 1) pre-pandemic experiences of remote work (“Before the pandemic, had you ever used remote treatment?”); 2) setting variations made during the first lockdown (“What setting changes did you adopt during the first lockdown?”); 3) current mode of work, exploring whether analysts still maintain the remote work and the reasons (“Indicate motives and reasons for current remote working use”); 4) personal opinion about online analysis (“Based on your experience, with which patients can remote work be used?”. Based on our clinical experience and previous study25, we included 6 options of response: Neurotic, Psychotic, Perverse*, Psychosomatic, Trauma patients, and an open-ended choice); 5) open-ended section for comments and considerations.

Data analysis

Descriptive statistics were conducted by means of the IBM Statistical Package for the Social Sciences (v.24; IBM Corp, 2016). Listwise deletion was used to handle with missing data (1.12%). Mean, standard deviation, frequency, and percentage have been calculated for all variables. The Chi-square statistic (χ2) was used to calculate the association between categorical variables. The acceptable statistical significance was set at p<0.05.

Results

Of 357 analysts and psychotherapists who opened the link, 267 (F=214, 80.1%) completed the questionnaire (response rate=74.79%). More than 80% (n=222) were aged greater than 46 years. Two hundred and forty-eight (92.9%) indicated working in the private healthcare sector. About 55% (n=148) work with children and adolescents, one-hundred and twelve (45.7%) work with the couple, thirty-nines (n=14.6%) with families and twenty-six (9.7%) with groups. However, most (n=261, 97.8%) work with adults (table 1).

Prior to the pandemic outbreak, more than 60% (n=167) indicated reported to have used remote work with patients, using videoconference sessions (n=131, 49.1%, e.g., Zoom, Skype), videocall (n=65, 24.3%), telephone calls (n=102, 38.3%) and email (n=1, .04%). The online analytic setting, before the pandemic, was more likely to be used by men compared to women (χ2(1) =4.716; p=.030) and among practitioners aged between 36-45 years (χ2(3)=10.331; p=.016). During the first lockdown, participants indicated to have introduced the following setting changes: temporary interruptions of sessions (n=124, 46.4%), sessions by videoconference (n=212, 79.4%), by telephone (n=186, 69.7%), and by telephone videocall (n=140, 52.4%). Moreover, other changes involved: sessions’ day (n=71, 21.6%), schedules (n=84, 31.5%), duration (n=12, 4.5%) and payment (4.5%, n=12). Actually, one-hundred and eight (59.2%) have restored the pre-lockdown setting, with a greater prevalence of women (χ2(1)=3.946; p=.047), while no age differences were found (χ2(3)=2.073; p=.557). Seventeen (6.4%) indicated an occasional suspension of in-person sessions, while a greater percentage (n=195, 73%) conducted remote sessions sporadically. The main motivations for still using on-line work occasionally were: patient or therapist positivity (n=188, 70.4%), patient request for non-health reasons (n=149, 55.8%), and personal needs (n=33, 12.4%). Of the sample, only 4.1% (n=11) no longer used remote work, while 2.6% (n= 7) still employed remote psychoanalytic work for patients living abroad.

Since the pandemic breakout, about 35% (n=94) of participants have started new treatment exclusively online, with a single-weekly session (n=55, 20.6%). The payment remained unchanged for about 28% (n=75) of the sample, as there is no difference between online and face-to-face sessions (more details in table 2).

Evaluating the remote experience overall, only 15% (n=40) indicate that working remotely positively affected the therapeutic process. Of these, 85% (n=34) had already used online analysis before the pandemic (χ2(2)=12.033; p=.002). In contrast, one-hundred eighteen (n=44.2%) perceived online interventions as less effective, and fifty-one (19.1%) indicated no therapeutic effectiveness with such therapy. Fifty-eight participants (21.7%) reported no opinion about teleanalysis effectiveness. No associations were found between perceived effectiveness and gender (χ2(2)=271, p=0.873) nor age (χ2(6)=3.865, p=0.695). For about 66% (n=175), online work constitutes a valuable tool in some situations. Regarding negative aspects of teleanalysis, participants indicate that, compared to the traditional setting, it fatigues more (n=191, 71.5%), requires more attention for privacy issues (n=118, 44.2%), reduces setting’s rigor (n=91, 34.1%), results more easily in the development of patient resistance (n=79, 29.6%), changes the asymmetry of the therapist-patient relationship (n=55, 20.6%), obstructs the processes of signification and elaboration (n=48, 18.0%) and both transference and countertransference (n=78, 29.2%). Regarding positive aspects of teleanalysis, participants reported that it facilitates the work with patients living abroad or hampered due to the in presence sessions (n=238, 89.1%) and reduces patients’ interruptions (n=118, 44.2%). The online psychoanalytic work seems more appropriate for adult patients (n=244, 91.4%), adolescents (n=139, 52.1%) and couples (n=81, 30.3%), while it would not perform well with groups (n=29, 10.9%), children (n=24, 9%) and families (n=17, 6.4%). Neurotic (n=219, 82.0%), trauma (n=118, 44.2%) and psychosomatic (n=87, 32.6%) patients would be most suitable for remote work compared to psychotic (n=41, 15.4%) and perverse (n=19, 7.1%) patients. Frequencies and percentages are reported in table 3.

Discussion

The present study aimed to explore the permanence of the setting modifications adopted during the covid-19 pandemic to promote continuity of care.

Our results confirm a wide spread of teleanalysis, even beyond the emergency condition. Such results suggest that psychoanalysts have recognized the development of new psychic phenomena within the remote analytic session that can be helpful in the analytic process. Moreover, this pattern of results further substantiates existing studies indicating that teleanalyisis, as it produces a trauma23, may facilitate the re-enactment of childhood trauma and its elaboration and processing25. According to initial hypotheses, analysts indicated several reasons, even beyond the restriction applied to prevent the spread of covid-19, for still using remote sessions, such as patients living abroad and patients’ momentary unavailability (conditions that already preexisted the pandemic). Moreover, analysts also listed other reasons, including having started new treatment exclusively online, presumably with patients living abroad or in other cities. In our opinion, such new patients would have merely used a proximity criterion to choose an analyst or, in the case of patients living abroad, they would choose an Italian native-speaker analyst. In the same way, analysts – before the pandemic – would have referred such new patients to nearby colleagues.

It is important to note that most analysts have not changed financial compensation, except in (rare) cases of changed economic availability of patients (dismissals, work stoppage). Remote work is seen as comparable to traditional face-to-face analysis; thus, remuneration stability allows the setting to remain as stable as possible, as a teleanalytic session is the only way to preserve the treatment and offers continuity of care.

Although analysts reported a negative opinion about remote work (i.e., efficacy reduction), more than 60% of the sample changed their opinion after the pandemic breakdown. The discovery of a new working method that in “exceptional cases” allows the continuity of the analytical relationship to be maintained is accompanied by enhancing its specific functions. Teleanalysis highlights transference/countertransference dynamics hidden in the traditional setting, facilitates the elaboration of some psychic contents, and allows patients’ greater openness and freedom than face-to-face work. Moreover, the change from office to home enables new associations and the observation of dynamics not revealed in presence. Such considerations suggest a cautious openness toward remote work. Although an initial scepticism, remote work, during and after the pandemic – represents a valuable (occasionally) working tool, as long as the analyst maintains rigorous psychoanalytic thinking about setting changes and their effects on the patient, therapist and relationship. The forced switch from face-to-face to a remote setting seems to have strengthened the confidence in the analyst’s internal asset, supporting «the valence of the transformative function of the analytic mind, internalized, likewise, by the patient. An internal arrangement, a transportable physical place, which has its natural location in the therapeutic space»30, a mental state31, in which «the crucial feature is the analyst’s focus on maintaining the patient’s possibility of a relationship and thought in analysis and, therefore, also not in co-presence»30.

However, teleanalysis is a kind of analytical work that constitutes a heritage for present and future psychotherapists. Bolognini, for example, stated that – despite the lack of closeness in-person – remote work enables emotional attunement and promotes significant analytical developments. Even in remote sessions, “profound things can happen”, and valuable interpretation helps the mutual work, highlighting phenomena hidden in the vis-à-vis therapy22.

Our results suggested that participants consider teleanalysis a viable tool in the therapeutic process, especially with adult neurotic patients. However, at the same time, the potential of remote work is thwarted with children and patients with severe functioning impairment, such as borderline, psychotic, and eating disorders patients.

The perceived fatigue associated with remote work could be due to the peculiar features of working mode, as “environmental intrusions” – foreign to the setting and the analytic process – make it challenging to maintain focus on the internal worlds playing in the analytic relationship. The negative aspects of teleanalysis (e.g., asymmetry, patients’ resistances) are related to the difficulties associated with working in the new setting: connection disruption, webcam position and reduction and unsustainability of silences (crucial interpretable phenomena for analysts).

Confirming initial expectations, remote work represents a valuable tool for conducting an effective analysis, as participants indicated no alterations in the dynamics of elaboration and processing.

However, analysts and psychotherapists were concerned about the closed-ended nature of the survey questions, as limited by predetermined responses. It is extremely challenging to evaluate a method (teleanalysis) that is as “novel” as its dynamic during these current circumstances.

Despite remote work is widely discussed within scientific debates, lectures and psychoanalytic papers, our results suggest an emerging need to share, to narrate personal experiences when the analyst and patient were not physically present in the same room.

Overall, the results of our study confirm the initial hypotheses: analysts and psychotherapists still use remote work in a kind a flexible way, not strictly related to health restrictions, suggesting an important change in the traditional rigorous psychoanalytic method, which thus accommodates the analytical work online, although it still adheres to the founding principles of the theoretical-clinical model.

Limitations of the study and conclusions

Our study is the first to explore the use and opinions of Italian analysts and psychotherapists with a psychoanalytic orientation about remote analytic work (teleanalysis) after the covid-19 outbreak. However, some limitations also need to be addressed. First, our study was conducted on a sample of analysts and psychotherapists of Italian Associations and Societies, where remote work is widely and extensively discussed. As a result, members may have declined the invitation to complete the survey. Second, participants were mostly private healthcare sector workers. Therefore, the current findings may not be representative of practitioners of the public sector. Third, our sample consisted mainly of senior analysts and psychotherapists (older than 46 years old), suggesting less participation of novice clinicians and, thus, precluding the generalizability of results to such group. Fourth, a self-report questionnaire with open-ended questions does not allow participants to give detailed responses about a complex issue. Including open-ended questions would help to understand better the complexity of the clinical experience that patients and analysts have faced in the past two years. Also, we have administered an ad hoc questionnaire. Future work should use validated measures to examine in more detail the online therapeutic process (e.g., therapeutic alliance, countertransference). Fifth, the cross-sectional nature of the data also precludes drawing any definitive conclusions. However, due to their descriptive intent, our results can provide a starting point for the epistemological debate about teleanalysis. Future studies could usefully examine the therapeutic process. Sixth, the proposed patients’ category (i.e., Neurotic, Psychotic, Perverse, Psychosomatic, Trauma patients), although theoretically and empirically substantiated, may be too restrictive. Future studies should evaluate in more detail the personality functioning of patients.

Conflict of interests: the authors have no conflict of interests to declare.

References

1. Ehrlich LT. Our sudden switch to teleanalysis during a pandemic: finding our psychoanalytic footing. Int Forum Psychoanal 2021; 30: 167-75.

2. Scharff JS. Clinical issues in analyses over the telephone and the internet. Int J Psychoanal 2012; 93: 81-95.

3. Scharff JS. Psychoanalysis online 2: impact of technology on development, training, and therapy. London: Routledge, 2018.

4. Scharff JS. Technology-assisted psychoanalysis. J Am Psychoanal Assoc 2013; 61: 491-510.

5. Bambini G, Ponsi M. La pandemia Covid e la “scoperta” della terapia a distanza nella SPI. Funzione Gamma 2021; 48: 98-104.

6. Backhaus A, Agha Z, Maglione ML, et al. Videoconferencing psychotherapy: a systematic review. Psychol Serv 2012; 9: 111-31.

7. Juhos C, Mészáros J. Psychoanalytic psychotherapy and its supervision via videoconference: experience, questions and dilemmas. Am J Psychoanal 2019; 79: 555-76.

8. Lemma A. Psychoanalysis in times of technoculture: some reflections on the fate of the body in virtual space. Int J Psychoanal 2015; 96: 569-82.

9. Bayles M. Is physical proximity essential to the psychoanalytic process? An exploration through the lens of Skype? Psychoanalytics Dialogues 2012; 22: 569-85.

10. International Psychoanalytic Association. Practice note on the use of Skype, Telephone or Other VoIP Technologies in Analysis. 2017. Available from: https://bit.ly/3T62JYP [last accessed March 2023].

11. International Psychoanalytic Association. Report of the IPA Confidentiality Committee. 2018. Available from: https://bit.ly/3mD2AQu [last accessed March 2023].

12. International Psychoanalytic Association. Recommendations for Psychoanalysts Regarding the Use of Videoconferencing in their Practice. 2020. Available from: https://bit.ly/3mGcroQ [last accessed March 2023].

13. American Psychoanalytic Association. Basics for Starting Teletherapy and Teleanalysis during the COVID-19 Pandemic. 2020. Available from: https://bit.ly/3LbZUUe [last accessed March 2023].

14. Cioffi V, Cantone D, Guerriera C, et al. Satisfaction degree in the using of VideoConferencing Psychotherapy in a sample of Italian psychotherapists during Covid-19 emergency. In: 2020 11th IEEE International Conference on Cognitive Infocommunications (CogInfoCom). IEEE, 2020. Available from: https://bit.ly/3YEfJGi [last accessed March 2023].

15. Migone P. La psicoterapia con Internet. Psicoterapia e Scienze Umane 2003; 37: 57-63.

16. Russell GI. Screen relations: the limits of computer-mediated psychoanalysis and psychotherapy. London: Karnac Books, 2015.

17. Sperandeo R, Cioffi V, Mosca LL, et al. Exploring the question: “Does empathy work in the same way in online and in-person therapeutic settings?”. Front Psychol 2021; 12: 671790.

18. Ferraro F. Scenari del limite: considerazioni sulla tecnica. In: Ferraro F, Petrelli D (a cura di). Tra desiderio e progetto. Milano: Franco Angeli, 2020.

19. Argentieri S, Mehler JA. Telephone ‘analysis’: ‘Hello, who’s speaking?’. Insight 2003; 12: 17-9.

20. Craparo G. Psicoanalisi online. Roma: Carocci Editore, 2020.

21. Zalusky S. Telephone analysis: out of sight, but not out of mind. J Am Psychoanal Assoc 1998; 46: 1221-42.

22. Goisis PR, Merciai SA. “Cosa abbiamo imparato”: conversazione con Stefano Bolognini. Funzione Gamma 2021; 48: 95-7.

23. Richard F. Psicoanalisi a distanza: Skype o telefono? 2020. Available from: https://bit.ly/3YxXzWS [last accessed March 2023].

24. Iossa Fasano A, Mandolillo P. Dal divano di Freud al monitor del PC. Milano: Franco Angeli, 2020.

25. Cantone D, Guerriera C, Architravo M, et al. A sample of Italian psychotherapists express their perception and opinions of online psychotherapy during the covid-19 pandemic. Riv Psichiatr 2021; 56: 198-204.

26. World Medical Association. World Medical Association declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA 2013; 310: 2191-4.

27. Lingiardi V, McWilliams N (eds). Manuale Diagnostico Psicodinamico - seconda edizione PDM-2. Milano: Raffaello Cortina Editore, 2020.

28. Freud S [1905]. Tre saggi sulla teoria sessuale. In: OSF, vol IV. Torino: Bollati Boringhieri, 1977.

29. Bergeret J. La personalità normale e patologica. Milano: Raffaello Cortina Editore, 2002.

30. Guerriera C. Introduzione. In: Vitiello L (a cura di). Tracce di pensiero nei solchi della pandemia. Dall’emergenza all’emersione. Roma: Alpes, 2021.

31. Bion WR. Attenzione e interpretazione. Roma: Armando Editore, 1987.