Anxiety, Uncertainty, and Resilience during the Pandemic: “Re-Directing the Gaze of the Therapeutic Couple”

The present global pandemic of covid 19 requires many psychotherapists to work at a distance via telephone or the internet. At the same time a considerable number of psychotherapists work with masks while maintaining social distance. This pandemic impact draws our attention to two questions: One is the difference of working within the office vs. working online. Two is how external events impact the individuals socially as well as personally. This chapter explores clinical cases where, even though Covid and its implications imposed a horrible loss and increas-ing day to day unpredictability on the therapeutic space, the focus of therapy was readjusted thus igniting a process of deeper self-understanding.


Introduction
On March 11, 2020 the world Health Organization declared COVID-19 to be a global pandemic. The threat of contagion, hospitalization, death, and loss cast its shadow on the world. Different countries used different lenses for viewing and dealing with the pandemic. Some people worked on the frontline, while others took refuge behind screens from their homes. The pandemic hit the least privileged populations hardest. Economic and social difficulties along with restrictions set the ground for unrest. Discontent and civil disobedience were notable themes for 2020 and 2021.
Several of my family members are of the "at risk group" so I immediately converted my private practice to an online format. I along with other fellow minded psychotherapists continued to work in front of our screens in our homes. I consulted with other practitioners and invested in a more effective social media platform, a better quality computer as well as microphone.
Teaching while carrying out my private practice is both challenging and satisfying. The shared space and how it is managed by the therapeutic dyad is often a strong indicator of what's going on in the interpersonal process. Delays, sounds, and gestures all provide nonverbal information for the working dyad.
The temporal and spatial aspect of face-to-face therapy and information exchange between colleagues provide a space/time for reverie [1] which is able to as well as an unleashing of the symbolization processes. Self-reflection enhances further reparative moves and thus allows for the remembering of parts long lost to the self. The tools for this treatment process have been conceptualized as the "work of mourning". Exploring loss with its intricate internalization processes, can emerge within a containing bi-personal mutually reflective field. The bi-personal reflective field is the unique ground from which a separate-level-reality is generated and rendered meaningful. Psychic maturation is initiated with the severing of the individual from the fusional state of total dependence on the mother and her body. This step is crucial as well as fragile. The individual throughout life will pendulate between approaching experiences similar to fusion with the mother and experiences of a separate existence from the mother. When an individual carries independence, curiosity and is externally bound, (s)he will be tainted with a sense of loss of union. The other (mother) represents nurturing, being contained, fed, utterly dependent, and in sharing a harmonious relationship.
In "The Interpretation of Dreams "(1911) Freud [4] emphasizes that experiencing concordance between internal processes and external reality results in a pleasurable discharge of tension. The fusional union refers to the collective experience that we all have had of once being one with our mother. Its divergence between internal and external will trigger unconscious memories of the loss of this fusional union. Divergence grants the reality of loss to settle in and prompts the process of reflection. In this fashion loss is the driving force behind the reflection process.
Factors such as hour, day, wage and room where the work will take place determine the "framework" of psychotherapy. Loss of frame, loss of transitional space, loss of room, and loss of psychosomatic presence began to constitute the emerging reality of online therapy. This phenomena presents itself as a twosided coin. The therapist must maintain a double presence that addresses what is being stirred up in the individual's unconscious while maintaining mindfulness regarding reality.
Loss is the driving force of psychotherapy and particularly in times of peril its concrete existence stamps everyone in a manner unique to each. The pandemic is an ongoing global threat, and its restrictions are disrupting our routine and sense of predictability. Uncertain conditions wreak havoc on the nervous system because the cycle of arousal and downtime is disrupted.
The cost of chronic and extreme wear and tear on our bodies, mind, and emotions has been coined as "allostatic load" by McEwan. In the face of threat or danger the body conducts a balancing act between the autonomic nervous system and the endocrine and immune systems.
Allostatic overload occurs when the demand on our internal resources exceeds our capacity. The fear and uncertainty fueled by the COVID-19 crisis is putting extreme pressure on our finite resources. The consequences include: poor decisionmaking, breakdown, and burnout.
Schwartz and Pines indicate that during a pandemic people (particularly health professionals) are dealing with two contagions, first the virus itself and second the emotions that it generates." Negative emotions are every bit contagious as the virus, and they are also toxic. Fatigue, fear, and panic undermine our ability to: think clearly and creatively, manage our relationships effectively, focus attention on the right priorities, and make smart, informed choices".
Contagion of emotions may be a reason behind increased demand on mental health professionals throughout this period. The therapist is always expected to be a gentle call to reality. The confined therapist who may also be suffering from confinement angst, health loss or loss of loved ones may be challenged in regard to their own sense of reality. As a consequence, the therapist must be being mindful of his/her own situation.

Technology friend or foe
Prior to the global pandemic, the procedure of telehealth has been a subject of disagreement in the mental health community. While some colleagues promoted psychotherapy online, others aggressively opposed it. During the 31st EPF conference in Warsaw a controversial panel was about psychoanalysis being conducted online. Heated positions against tele-analysis stated that several internet platforms stored session data on their servers and that a potential breach posed a significant confidentiality risk. In addition to this reliance on technology, online therapy introduces complications. Technology sourced delays, disconnections as well as screen fatigue are teletherapy concerns.
Those in favor defended their position by stating that the territorial expansion of psychoanalysis allows analysts increased flexibility. Psychoanalysts now have the option of traveling or settling in remote areas while they continue to work. The increased convenience and flexibility of working online is a democratizing movement because it allows easier access to psychoanalysis for those who cannot commute due to their location or disability. This shift results in easier access for the analyst as well as their client. Some stated that psychoanalysis could benefit from the online revolution and become less elitist and easier to access. Developments in technology are allowing communication platforms to be more reliable. After the onset of the pandemic the psychoanalytical community has started to seriously discuss territorial expansion and tele analysis as an option to psychoanalysis. The related Practicalities can be deceiving. Their opportunities as well as consequences must be considered. Technology has invaded the therapeutic link. People are beaming into the therapeutic space within seconds. Practicality and immediate access to the therapy space has robbed therapy of its time demanding aspect. Time has a structure providing function and gives way to predictability regarding the future. Deep reflection, and the related emotional processing regarding internal work often takes place in the time and space before, during, and after therapy. The seamless image of online therapy has robbed the therapeutic interaction of its traditional time sequence which allowed a gradual unraveling and emerging of unconscious dynamics.
The online format which technology provides us allows wider access to therapy. Not having to leave home or the office had some people thinking it would be easier. Individuals who were avoiding the tides of their inner world with external activities were forced to see beyond the pure physical aspect of themselves and their relationships. Previous pursuits started to lose meaning. One man found he was at odds with people he thought were his close friends and found that it would be worthwhile to prune off the weeds in his social network. He started working with a psychotherapist face to face regularly. Another man seeking therapy stated that starting psychotherapy was long overdue, the anxiety he had felt since childhood was getting worse each year. The restrictions imposed by Covid put a break on his socialization activities and he started to reflect on his life's course. Willing to work online made it easier for him to start therapy without breaking from his work or domestic responsibilities. All that a therapy candidate needs is access to technology.
The physical presence of the therapist has a containing, and a holding function. It serves as a Winnicottian "environment (m)other. The "environment mother" corresponds to the 'holding' stage of maternal care, and the complex events in an infant's psychological development that are related this holding phase. Technology allows for transborder psychotherapy and this development may permit the omnipotent illusion of omnipresence. The illusion of a therapist who can be reached through a single click may form a pretext for avoidant individuals to continue to Anxiety, Uncertainty, and Resilience during the Pandemic: "Re-Directing the Gaze… DOI: http://dx.doi.org/10.5772/intechopen.98234 hide from the physical world in a virtual one. Therapy conducted without physical presence can be misleading and may lead to unrealistic beliefs regarding the therapist to take root.
Merve, who lived in a different city and consulted with me during the pandemic worked with me for several months online. I was intensely focused on her face, yet missing cues from the rest of her presence. One day she requested to visit me in my office and said, "Every week I see your face and hear your voice however I don't know how you occupy space, how you move, or your height".
She was missing her fantasy of seeing me face to face as opposed to seeing me online. On one hand, anonymity may have its advantages because it allows the patient the freedom to project. Merve held the belief that if she saw me, she could truly know my situation and feel reconfirmed. It would be oversimplifying to assume that since she now met me in person, she actually knew my true situation however seeing me in the same room deepened the impact of our work. Merve is a healthcare professional who is working on the front line of the pandemic so her need to ensure that I was real and intact may have been an enactment that satisfied her need for predictability under very unreliable circumstances.
A therapeutic relationship taking place in a common space tolerates silence, yet technology driven shared cyber space switches off following extended silence to conserve energy and bandwidth. As silence becomes even more unpredictable, online therapy's related silence tolerance is diminished, thus silence's meaning has shifted.
Variables such as space, time, and social engagement can become two-dimensional thus depriving the encounter of depth. The wholeness of the experience of psychotherapy in my mind is compromised for both parties. Face to face in-depth psychotherapy can elicit vivid, visceral emotions that can be reflected upon. The stage of the therapeutic room becomes complex and intense, yet the voice and presence of the therapist is a gentle call to reality.

Imposition on the therapeutic space
Telehealth has reshaped the therapeutic community. The setting and the frame of; training therapists, providing clinical supervision and conducting therapy have been beamed into cyber reality. The shared common room is replaced by two independent spaces connected through technology. The shift from a therapy room to an internet link entails a convenient speedy connection which comes with consequences.
The "Psychotherapeutic" frame and setting binds clients to their session. The hour, the day, the place, and the fee are the conditions of therapy. This framework of rules, with all its impracticality and reliability, opens a window into exploring archaic symbiotic links lurking in the backdrop of individual minds and psyches. The frame provides an opportunity to explore internalized primitive family institutions as well as unconscious aspects of identification with self and others. Factors such as hour, day, wage and room where the work will take place determine the psychotherapy "setting". This setting allows the individual to establish their "unconscious theater". Individuals who distract themselves from their internal conflict or emptiness with daily activities may react positively or negatively to the binding date and time of the therapy session. Commuting to the session, being on time, being greeted by the therapist in the room, settling in the room and ending the session on time, exchanging money and saying goodbye are part of the process. Difficulties in reunion and separation for each session can be an indication of an individual's need to establish closeness and distance with their own internalized parents [5].
Shortly after the pandemic became widespread, an avoidant woman in psychotherapy named Ece, displayed relief at not having to commute so long to each session. Ece had consulted with me because she felt isolated and anxious and suffered from social inhibition. Several years of psychotherapy had helped her in this regard, and we were in a stable stage of pre termination. Shortly after moving online, she had troubling dreams of a strange ghost-like woman haunting her bedroom and invading her privacy. As we worked through her dream it became clear that my virtual presence in her bedroom was evoking archaic fears that she had regarding her mother as an unconscious object of fear and desire. When working face to face, the commute to and from my office allowed her to regulate and deny these unconscious feelings. The fact that there was no time between work and therapy had robbed her of a space which gave her peace of mind yet was flooding her at night. The reality of my cyberpresence in her bedroom, was perceived by her as a psychic invasion. The new situation demanded that we reflect on an aspect of her that may have remained undercover in our former traditional mode of working face to face. As any new situation brings up issues, I want to highlight that perhaps what may have gone unnoticed was converted into the material of psychotherapy.
Factors such as space, time, and social engagement become two-dimensional and can deprive the encounter of depth. The wholeness of the experience of psychotherapy in my mind is compromised for both parties. Face to face depth psychotherapy can elicit vivid, visceral emotions that can be reflected upon.

Loss of physical presence
Confinement and social isolation coupled with constant partner and children interaction is imposing a different kind of fatigue. Pleasure providing pre pandemic activities such as holidays, sports, concerts, theaters, movies, meetings and social activities are no longer safe, accessible forms of socialization. The physical expression of greeting and meeting has evolved into a now prohibited red flag. Shaking hands, touching, face to face social engagement and all similar prosocial behavior is suddenly imposing a huge threat. It is a dystopia of isolation. The cyber-illusion occurs at the expense of loss which is not acknowledged. The loss of bodies in the session room, sudden access and an ability to move seamlessly into and out of the session is impoverished by the loss of physical encounter for the individual partaking in therapy. The cues that the individual nervous systems signal as well as the related micro expressions provide each party with a rich source of information. The material embedded in the unconscious shadows of individuals and couples may remain hidden in this frame that is lacking physical interaction.
Throughout my own clinical work and those of the colleagues with whom I consult, the impact of the loss of our common session room is expressed in different ways. Some clients were linking to therapy from inside their cars. Many of them claimed to lack a physical space to think, some of them claimed to need the car as a confined space that would contain and transmit them. Internal and external conflicts of individuals who do not have an internal mental space to reflect emerged during their sessions.
The presence of the lost common area is undoubtedly important. "Sharing assets together" within the same room provides data to both the therapist and the client. Reactions, sighs, silence are all experienced in the process and in the room. While the coverage takes place in a three-dimensional space in the common room of two bodies and dual minds, the session was no longer taking place in the therapist's area, but in uncanny cyberspace, which intermittently transmits latency sensitive sound and image. The shape of silence has changed. Since some platforms are deactivated in the absence of sound, long silences were replaced by expressions such as "hmm," "aha", and "yes".
The screen, by obscuring the presence of the body, can withhold information. Individuals can hold sessions wherever they want by placing virtual images on their background.
The next example illustrates how the "loss of the room to zoom" was denied and how it was enacted in the therapeutic space.
As a small child Derya, has memories of being severely shamed and subject to physical abuse. As an adult she suffered from somatizations, fainting spells and depersonalization. A small child often lacks sufficient ego autonomy to integrate the experience of being beaten and shamed. Integration of the agony of abuse by a parent is not possible because the child's ego organization is not sufficiently developed. What complicates the matter even more is that the abuser is also the parent who protects and is relied on. This conundrum is so unbearable that the psyche of a developing child will survive by splitting internal parental configurations. Such individuals will have difficulty tolerating ambivalence in the future. People and events can be perceived as either torturing, abusing or protecting and stifling. Derya recounted experiences of losing a sense of inhabiting her body (depersonalization) and a loss of her sense of reality.
Derya was required to move to another country during the pandemic and continued therapy with me. Several months later when she planned to return to her native land, she shared a dream that goes as follows: "I am going back home yet everything is upside down. Nothing is in place. It is my home, yet it does not look like it. Two women greet me, I don't recognize them, but they know me. The younger one said she is glad to have met me, the other one gives me a big hug. I rush about trying to straighten out the house before my husband and daughter come home. They come home but my daughter is suddenly a small child, and my husband is holding her by the hand. I feel all alone. I am stunned and confused and not sure what to do." She insisted that she felt no fear but only horror. She felt the confusion to be a way of concealing the horror she was experiencing around reuniting with her therapist. During the pandemic I had moved my office and she had not seen the new space. Though very capable at navigation she was convinced that she would not be able to find the new building and office. Our online encounter provided an illusion of omnipotence. The former obstructions of parking and fighting with people enroute to her sessions with me had disappeared and remained underground for quite a while.
The reliable facilitating environment of the consulting room and its couch had been compromised and the fact that she was returning home and possibly to a new office had impinged on the mental refuge that she had established. She was returning to her treatment which became a possibility as the situation of the pandemic improved.
This dissociation found expression in her horror around not being able to find my new office. She had identified me and my former office space as one, and my moving, split my existence in her mind. My move elicited fantasies about what I had abandoned by moving to this other place. Reality does have an impact. All sorts of factors play in. The loss of access to the physical presence of the therapist along with other restrictions imposed by the pandemic set the ground for an internal breakdown. The Fear of Breakdown (Winnicott) is an organizational structure which is a defense against a state of agony that was encountered yet not integrated by the individual. In Derya's case her internalized sense of agency at being able to make it to her therapist's office broke down like a small child who gets lost and cannot find her way home.

Gazing at the reflection of other
This clinical vignette illustrates how current focus on racial discrimination on one hand and pandemic inspired online psychotherapy influenced the treatment. Better understanding of race opened up additional perspectives and played its way into the treatment. According to Mitchell [6] the self craves affirmation and validation from other selves: "Being fully human (in Western culture) entails being recognized as a subject by another human subject. There is a deep, ongoing tension between our efforts to have our own way, as an expression of our own subjectivity, and our dependence on the other, as a subject in her own right, to grant us the recognition we require … (p. 64; italics in original) Although a vast array of literature is beginning to emerge on intersubjectivity, there is very little on its implications in intercultural therapy [7]; has discussed the mirroring function of the gaze of the (m)other as this impacts self-esteem in terms of race: the (m)other gaze, the mirroring function, whether transforming (Winnicott) or de-forming (Lacan) is internalized and becomes part of an internal/external dichotomous perception of the self … (p. 237)".
Laura is in her thirties and married with two children. Her father is a black American man and her mother is a white European woman. She is estranged from her father due to his philandering and general lack of interest in his children. Her mother is a distant woman who later married and had another child with her second husband. She grew up with her mother, sister and stepfather.
She consulted with me approximately a year before the shift to online. She was pregnant for her second child and wanted to make sure she did not mess up the way she thought her mother had. It seemed like she was continuing therapy to enhance her mothering skills. My psychodynamic focus was on the internal struggle between her "denied wish to unite with her mother" and "reluctance to emotionally acknowledge her passage to full frontal motherhood".
Upon the birth of her second child (who had darker skin and curlier hair than her first born) she was an ecstatic and devoted mother. She did not want to nurse as long as she had with her first child. She suffered intense back pain, and rapid (unintended) weight loss following her delivery. She found it easier to delegate her second child's primary care to the babysitter.
The external reality of that particular year 2020 was "pandemic induced confinement" and the news was flooded with violent polarization between those identifying with racial differentiation and (its evil twin) racism and those denying it. In regard to racism, she spoke with compassion yet maintained her distance and claimed that she did not understand what it meant to be black. Her husband lovingly joked that she was the only one who did not know that she was black. Her mother, sister, stepfather, partner and first child were all "white". During our appointments her hair was generally done up or blown dry straight. One day it was loose and curly.
While I was privately admiring her hair, she spoke about her former best friend from whom she had been estranged from for 10 years. While she realized that their relationship was toxic, she could not understand why she was so fixated on her. She explained that this woman was the only black friend that she had ever had She could not understand why her estranged friend was always on her mind. She suddenly looked at her image and said, "My hair is disgusting today" and did it up. I was reminded of African feminist Ngozi Addichi's statement around race, femininity and hair. Addichi states, "Hair is the perfect metaphor for race in America. It shows the small ways in which racism transcends into seemingly trivial things, like beauty" I observed this woman responding seemingly violently to her own "crowning glory". I commented that Zoom was making it impossible for her to hide the image of her textured hair from me as well as from herself. She gazed at her image and her lips curled in a way that may have been indicating disgust. She pivoted between images, affects and emotions while recalling memories of her white mother's indifference about her hair and its special needs. She recollected the loneliness and shame she felt in elementary school when her classmates teased her and called her hair ugly things. She expressed nausea, feeling unclean and dirty.
Jessica Benjamin states that the maternal gaze allows for the recognition of the similar as well as unique aspects of the self and other. Laura had not embodied the experience of being noticed for an aspect of herself that was different from her mother. I hypothesized that the racial indifference Laura's mother had towards her daughter, internally hindered Laura's ability to self-identify as a black or biracial female.
This unexpected third (her own camera induced image) invaded our therapeutic space. She felt exposed and naked. When I inquired "if I were black how it would have been?". She made it clear that she would have felt judged if I were dark black. As a white person I could not understand her experience. She was able to admit that it was only someone who was black but light enough to pass as white could understand her. She was discriminating against me for not being her color. I, due to my skin color, in her mind, just like her mother, could never fully understand her. She isolated herself again then from her mother and now from her therapist. Holding on to the belief that "She could not be understood" had been her anchoring identity. Letting go of that belief put her in a position of mourning which ultimately led to her realizing reparation and relief. Acknowledging her anchor in hate constituted a milestone in her therapy. During the following session she spoke of her younger son and how it broke her heart when he cried and about how angry she got when her husband expressed discomfort regarding their son's tears. As she softly began to cry, she stated that gazing at the image of her son cry was like seeing herself cry in the mirror and that they both had ugly cry faces.
True understanding is possible by encountering the alien [8] writes "I can deeply appreciate an aspect of me because your experience of that aspect of me provides a reference point that in relation to mine, expands my experience from a psychic singularity to one that is elaborated, dimensional. With myself, I can be; but with you, I can become." By looking at maternal indifference through a lens of motherhood and race, Laura was able to create a link between her hesitancy with her son and her fear and guilt that stemmed from being indifferent to her son in the way that she had experienced with her own mother. Bleger [9] points out that individual identity is always conceived as being embedded within a context of an undifferentiated social framework which resonates a silent and unrepresentable not-me part of me. It is only through the gradual processes of representability that individuality can eventually emerge from the encompassing impersonal collective cultural context. These endless identifications within the ego, resulting from a constant exchange with the Other-than-me, cannot but create constant modifications of the 'I am's' constituent components. The illusory and deceptive state of unity that we are used to calling 'identity' turns out actually, to be in a state of perpetual fluidity.
Laura's experience of seeing herself in the face of her crying child, and as a woman with curly hair corresponded with her unique representation in her inner world. To hide behind the justification that it was the experience of every biracial women would rob her the opportunity to build herself a more complex and multidimensional representation. The ego is constantly reidentifying itself resulting from a constant exchange with the Other-than-me. The illusory and deceptive state of unity that we are used to calling 'identity' turns out to be a state of perpetual fluidity. Encountering the therapist as the other is what facilitates this dynamic change of representation.
I believe that my ability as her therapist, to appreciate her uniqueness, when coupled with her own image, allowed her to initiate the process of her identifying with her blackness. This identification process is possible only after she mourned her internalized maternal image that did not appreciate her uniqueness and did not mirror her as a primary self-object would do in normal development [10]. The image on the screen directed our joint attention to the visual aspect of things.
In depth psychotherapy allows this difference to emerge. By uncovering her erroneous idea that someone who does not look like her could not understand her, she could deconstruct her belief that only people who were similar could understand each other.

Conclusion
The self of the individual is embedded in a system. Behavior, unconscious motives, cognitions, somatic responses, affects, and emotions are a function of the self, embedded in its internal and external interactions and corresponding dynamics. The subject of therapeutic encounters is the meeting of minds. Therapists provide a space in which the self can think about the system that they are functioning in, be it internal or external. "Therapeutic thinking" (aka reflection) is a rational, emotional as well as somatic experience that takes place between at least two people. Not unlike the parent infant bond, it has its own style of attachment, dynamic pattern, organization and rhythm. In-depth therapy gives space and time to the individual which is used to dream, remember, experience, think, and feel. Tele psychotherapy demands a shift in the "frame" of therapeutic work. The therapeutic dyad is now sharing a technology based connection instead of a joint room. Sessions can be conducted from any location therefore the containing function of the room is lost. The nature of the therapeutic relationship has shifted drastically. This shift entails loss and change. The meaning of loss is repositioned. Online therapy can entail an attempt to deny the loss of space as well as a refutation of the fatigue it imposes. The information conveyed between individuals is now limited to words. The individuals no longer have direct access to the clues provided by the soma and nervous system since they are subject to the internet or telephone line. It is impoverishing to compare the old format with the new. The new situation is unique and has its own distinctions. Training programs are redesigning and rescheduling their programs.
A generation of therapists trained online is on the way. I find myself yearning to connect in the same room with my younger colleagues. I risk flooding them with excess clinical experience. This deluge might be a means to alleviate my feelings of regret surrounding the nature of our new learning experience resulting from not being in the same room. Freud [11] in his seminal paper on Transience (1916) (1915), when he describes a walk with a friend and a famous poet, writes: "As regards the beauty of Nature, each time it is destroyed by winter it comes again next year, so that in relation to the length of our lives it can in fact be regarded as eternal. A flower that blossoms only for a single night does not seem to us on that account less lovely." Freud articulates a fundamental aspect of the experience and its unavoidable consequences and fears. Apathy is an expression of the anticipatory mourning and the risk of the withdrawal of affection from pleasure giving objects as an experience that is damaging. "On Transience" suggests that the environment and affectively invested objects can be experienced in a peculiar atmosphere of loss and fear of the end. The