key: cord-0821960-p33m2jhm authors: Chong, Seng Choi; Ang, Jin Kiat; Tan, Khai Pin title: A “good enough” remote psychodynamic psychotherapy – a psychiatry trainee’s novice experience during Coronavirus pandemic() date: 2021-09-07 journal: Asian J Psychiatr DOI: 10.1016/j.ajp.2021.102835 sha: 9783c22ba045381f84cde19854eebaecb7e210f2 doc_id: 821960 cord_uid: p33m2jhm Covid-19 pandemic and the public health measure have forced an en masse transition to remote therapy from physical sessions. Remote psychodynamic psychotherapy is not a new treatment modality, but its effectiveness in holding the analytic frame has been concerned by some therapists. We would like to highlight some of the therapeutic processes involved with remote psychodynamic psychotherapy, via the help of a narrative experience of a psychiatry trainee who was novice to this delivery method of therapy. Reflections on these concerns have been made in line with the experiences highlighted. Since the coronavirus disease outbreak in 2019, it has yet to show any signs of abating. As people is unsure how long it will last, the public health measure of physical distancing has forced an en masse transition from physical to remote therapy. Remote therapy is when both therapist and patient are not present in the same room, but is conducted via telephones or technologies such as Skype, FaceTime, Teams, Zoom, etc. While the therapists need to be sufficiently confident with these innovations of therapy delivery, they often have other issues to consider besides the access to technical support. Across all therapy modalities, concerns have been raised about whether a good working relationship can be established online, apart from the ethical and confidentiality issues (Connolly et al., 2020) . Though remote therapy is not a new treatment modality, many psychoanalysts and psychodynamic psychotherapists seemed to have additional concerns regarding the violation of the analytic process and analytic frame (Scharff, 2018) . Many opine that remote analysis could be a distortion of the analytic frame, which cannot support an authentic analytic process (Scharff, 2013) . Although careful attempts could be made to hold this frame via regularity of treatment process just like physical sessions, remote method has its own challenges. However, in response to the pandemic, all therapists must improvise new ways of delivering psychological treatment (Scharff, 2018) . We would like to highlight some of the therapeutic processes implemented via remote therapy, with the help of a narrative experience of a psychiatry trainee who first conducted online psychodynamic therapy for his patient who suffered from narcissistic tendency and struggled with imperfections. Reflections on these concerns have been made in line with the experiences highlighted. "I was totally lost when I first started the psychotherapy. Due to the current pandemic and restriction, the whole psychotherapy had to be conducted remotely. The lack of physical presence in remote therapy might interfere with the therapist's provision of holding environment (Migone, 2013) , but in this case, the medium through which psychodynamic psychotherapy was delivered had instead served as an external holding object for the novice therapist. When he and his client entered the therapy, they brought along the ongoing acute trauma (i.e., the sense of national catastrophe in times of loss experienced during this pandemic) and unresolved traumas that the acute wound had stirred up ( i.e., the personal vulnerability relatable to one's own psychic experience). Hence, they mirrored each other and slid into reenactments with the use of this technological medium. The therapist felt inept to remedy his patient's imperfections. Therefore, the use of remote therapy in this aspect might also create a sense of loss, or even be traumatizing for both the therapist and the patient (Argentieri, 2003) , if the transference and countertransference are not kept in mind. "The beauty of psychodynamic psychotherapy supervision is that the reflection was for the patient and therapist. Many therapists concern about the impact of remote analysis on the transferencecountertransference. Our psychiatry trainee w h o identified with his patient's J o u r n a l P r e -p r o o f vulnerabilities and enacted by attempting to use the digital screen to foster the development of an illusory, idealized image of an experienced therapist (Roesler, 2017) , was an indicator that this analytic process could still occur. However, some analysts might find it hard to endure and consider this experience as an intrusion of work into personal space and feel like an arduous in relation to the constrictive needs to stay within the view of a digital screen (Svenson, 2020) . Additionally, I was also worried whether I could show empathy to the patient virtually. The concern for a good working relationship also involves question if the therapists could connect emotionally with the patients. The lack of embodiment and non-verbal cues might dull therapist's sensitivity to unconscious affect (Scharff, 2010) . However, these limitations ought not to inherently create distance. Instead, it may unearth the deep emotional wounds around distance in both the therapist and patient (Ehrlich, 2019) . A "good enough" remote psychotherapist is sometimes more important, just like the concept of a good enough mother (Winnicott, 1953) . She needs not to be perfect, but just good enough to be present and emotionally available to the child. There is also the question of the loss of familiarly structured therapeutic spaces which one encounters in physical sessions. While it seems what the therapists could obtain i is only on and from the screen, some also find that the screen changes the texture of human intimacy. We do remain fully frontal for 50 -60 minutes with personal space is seen, thus, feeling exposed and ashamed (Svenson, 2020) . By considering the real impact of these technical challenges and practical impossibility encountered by the patients, we ensure ourselves not coming across as rigid adherents to the analytic frame, which could lead the patients to experience us as lack of human touch in helping them. To overcome these challenges, our psychiatry trainee had prepared himself by speaking to his peers who had conducted online therapy, reading guidelines on J o u r n a l P r e -p r o o f remote therapy, and by having weekly supervision. He had also prepared the patient with an early discussion on the delivery method and t r e a t m e n t contract emphasizing on the assurance of treatment setting at both ends was private, with no risk of being overheard or intruded upon, in line with the advice of the Confidentiality Committee of the Institute Psychoanalytic Association in 2021. The trainee also chose his regular clinic room for sessions to avoid distraction and to give a psychical sense of security to the patient, thus, maintaining his professional demeanor and commitment to their work. We would like to summarize the trainee's experience with remote psychodynamic psychotherapy from the eastern concept of kintsugi where it is about picking up the broken pieces of self, joining them back together with gold, and re-assembling the beauty underneath the scars. In present situation, coronavirus represents the reality of a life-threatening illness (real angst) (Freud, 1926) . It denotes a form of acute trauma, soon to be chronic for everyone. Thus, we process the same trauma our patients do (Svenson, 2020) . Even though the pandemic may seem to have ruptured our existing world, it does signal an inflection point, "when opportunities and risks multiply ... and when new structural scaffolding is erected" (Spoonley et al., 2020) . Sustaining and promoting social cohesion should be a key consideration as we embrace the concepts of non-attachment and acceptance of change. A mindset of perfectly rhymed in-person work must be addressed with the capacity to let go of the imperfections. Nevertheless, hope is to be kept in a thoughtful remote therapy; it will preserve the analytic frame, though it stretches it. Written informed consent was obtained from the patient. De-identification was done. Nil. Nil. Telephone "analysis": "Hello, who's speaking? 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