This is a brief communication inspired by the recent Coronavirus pandemic, which has prompted us to update our clinical and conceptual tools so that we can continue with our patients' analytic process despite the restrictions imposed by the risk of the Covid-19 infection. As child analysts, we are used to working in a setting that offers parameters of stability and continuity, but recently we have had to change our usual setting parameters with children, in a way that was not unlike the changes we had to make with our adult patients. Our personal experiences have shown that remote sessions constitute a valid alternative to, the now unfeasible, meeting in person, even though we are aware of the inevitable limitations that the absence of actual physical presence involves.
So we would now like to show how the body-mind relationship plays an important propulsive role in remote analysis with children during the pandemic, with the help of some brief clinical sequences from two sessions of the analysis of one child. There is theoretical support for our approach, but we prefer to offer the reader an intuitive approach from our experience (Bion 1962) and to focus on the clinical material first, touching briefly upon the theory only thereafter. By way of orientation, we should not fail to consider that the body exists in space, as Freud pointed out (1923), and as a result its spatiality can function as a sort of house where the subject lives, which can help in learning to bear the loss of the customary context of the analyst's office and the physical presence of the analyst, when the pandemic has swept away these familiar qualities. This in turn can contribute to a reinforcement of the ego, thus fostering the general evolution of the analysis itself.
I want to thank Riccardo Lombardi for his thoughtful suggestions.
Sara came to her three-sessions-a-week analysis at the age of six and a half because of her paralyzing depression and loss of vitality, with bed-wetting and compulsive anal masturbatory behavior. According to her parents, Sara couldn't sleep in her own bed and she often was unable to stay by herself in her room, even briefly. She would spend hours by herself in the bathtub, relaxing and playing with her anus and feces. Bedtime was regularly a trigger for profound and unbearable anxiety. Sara was always eager to come to her analysis and was often reluctant to leave at the end of the session. In the analyst's office she moved around the room bumping into the wall and against the chairs and the table, apparently oblivious of where her body ended and the world around her began. Her first months of analysis made it possible for her to reduce her compulsive behavior and to become more aware of her bodily boundaries, to the extent that she could even sleep in her own bed, instead of that of her parents. In March 2020, after only eight months of her analysis, Italy declared a lockdown of indefinite duration, so we were obliged to suspend our sessions in the office. Fortunately, before the new ruling, we had talked, during a session, about the possibility of having online sessions from home and Sara was amenable. Her parents also agreed to the possibility of online sessions.
At the beginning of Sara's first remote session, she hides at the side of the screen while her father says, “I'll leave you here alone in your room with the doctor.”
Sara remains hidden beyond the edge of the screen.
A: “We have a bit of suspense now. I can't see Sara yet.”
[At this point she appears and waves her hand. She pushes her father out of the room, saying “Go away!” She's wearing pajamas decorated with pandas, an animal she's extremely fond of, and she's holding a small panda doll in her arms.]
S: [to me] “Can I bring her with me?”
A: “Sure. Now we're all here together.” I take the dolls from the toy box in my office and hold them up to the screen.
Sara: “Show me my two favorite dolls.”
A: “Here they are on the table.” I place the two dolls where she can see them. “And here are your box and your folder of drawings.”
Sara: “I miss you! Will we see each other…” She thinks about it for a moment. “Thursday?”
A: “I think it will be a little bit longer. Meanwhile we can continue our sessions online.”
Sara: “Look, I'll show you my Little Panda.” She puts the stuffed toy in front of the screen. “She's my baby.” She hugs the panda on her lap. “Look, these are my pajamas just like a panda. Look, I even have a hood.” She puts the hood on her head, obscuring half of her face. Then she stands up and shows me her tail. She sits back down and picks up the toy panda again. “Here she is, can you see where she sleeps? There's her bed but, as I told you, she doesn't want to stay there because she wants to sleep here with me.” Then, in a motherly voice, directly to the panda: “You know you have to stay in your own bed. Come on, try to sleep a bit here, darling.” She looks at me on the screen and says, “I go to bed and she wants to get into bed with me.”
A: “Just like your panda, you too are trying to get used to staying in your own bed, in your own space and taking care of yourself.”
Sara: “Look what I'm putting next to her bed!” I watch as she places an inflatable mattress between the panda's bed and the wall. “I put this here, so she doesn't hit the wall. I use one too, so I don't hit the wall either. I forgot to tell you, I hit my face here, and one time my leg and knee.”
A: “Ouch, how awful!”
Sara: “Yes, but I don't even know how I did it.”
A: “Your body isn't made of rubber, is it? Thanks to these little bumps you can feel where your own body is.”
Sara calls our attention to her panda pajamas, bringing to mind the importance of her bodily covering that envelops her, contains her and defines her bodily boundaries. Whereas the panda pajamas represent a possible skin that contains her, her panda toy can be regarded as an
object of her care that helps to orient her toward taking care of herself. This working through helps Sara to accept separation before sleeping and to better contain her related anxieties regarding the existence of her own body. Furthermore, the pain she felt when she bumped herself on the face, leg, and knee represents progress towards the discovery of her bodily geography, with an awareness of its distinct parts (body-mind vertical axis of elaboration).
Sara: “This is my light for the night.” She shows me her bedstand light. “Now I turn it on and then I turn it off.” She switches the light on and off. Sara disappears from the screen and I can't tell if she's hiding or if she's just turned off the light. Then I hear a voice. “Guess where I am!”
A: “Hello!” She doesn't answer. I decide to send a message and write, Sara, you should at least leave the microphone on so that I can guess where you are.
Sara: After a few minutes, she reappears on the screen. “I'd put my hand over the camera.”
A: “Now I can see you.”
Sara: She takes the computer and rotates it to show me her room. “Here's my wardrobe. Come on, I'll put you in here.” She encloses the computer in the dark wardrobe.
A: “Knock, knock, knock.” I knock on my table. “Let me out!”
Sara: Sara opens the closet door. “Bye-bye.” She closes the door again.
A: Even though this is virtual, I have a claustrophobic sensation, as if I were a Lilliputian at the mercy of her hands.
Sara: “Here, the door is open.”
A: “On the computer, I can be with you only if you want me to.”
Sara: “Now I'm tired. How many minutes do we have left?”
A: “Only a few minutes. It's natural for you to feel tired when you try to hold your strong emotions in for a meeting on the computer.”
Sara: “One, two, three. We have to say goodbye.”
In this fragment of a session, Sara first disappears from the screen and later invents a game of putting the computer in the closet, and, by association, putting the analyst in the closet, giving us another example of the way in which she confronts separateness. This illustrates how working remotely strongly affects Sara's analytical process. The analyst, in her countertransference, experiences the same sense of paralyzing helplessness as the child.
The passage from Sara's total disappearance, when she covers her video camera, to the wardrobe game implies a step forward in her working through, since the computer placed inside the closet spatially defines a differentiation between the child's space and the analyst's space. The confrontation with this differentiation takes place with the significant emotional participation of the analyst, who feels diminished in size by having been controlled by the child. This brings to mind the intensity of the projective communicational identification (Bion 1962), even at a distance. Finally Sara realizes she's tired, as a result of this important emotional work and of her ability to be in contact with her depressive feelings, which have been supported by her analyst's participation. Sara's question, “How many minutes do we have left?” emphasizes a growing mental awareness of time emerging within her. Her perception of time is accompanied by her sensorial perception of being tired as a consequence of having worked through her spatial separation from her analyst. In other words, space and time are in the foreground, because of the growing spatio-temporal differentiation within the analytic couple. The analyst helps the patient to bear her exhaustion while at the same time supporting her mental perception of time.
Let us now consider some passages of a subsequent session.
Sara: “Look, I have a double bed, one for Little Panda and one for me.”
A: “Now each of you has her own bed and space.”
Sara: “Panda doesn't sleep alone, she sleeps near me.” She speaks to her
Panda. “Listen, Panda, later we'll go to the park.” Sara now directs the conversation to me. “After I went to the park, look what happened!” She moves her face closer to the screen. Her chin is red and irritated. “I haven't put on any cocoa butter since Saturday!” She calls, “Papa, Papa, bring me the cocoa butter!” Without a pause, Sara continues, “Look how good I am at making my bed!” She disappears from the screen. “Don't worry, I haven't disappeared.” Sara's face reappears on the screen. “I went to the other side near the wall to fix the bed so Little Panda and I don't fall out. I fall out of bed a lot, but now I can fall and climb back in.” She moves in front of the screen as if she were trying to show me her body. “Here, I also have a sore spot in my mouth.”
A: “Now you are discovering things about yourself and your body, your sore chin and the sore in your mouth.” I pause for a moment. “Even falling, like falling off your bed, can be tolerable when you have a body of your own.”
Sara: “I'm teaching Little Panda and my toy dog to do yoga. Look, here's my sister's watch!” She shows me the watch on the screen. “I have to put on my cream again.” She leaves the screen to get the cream and then returns. “Ah, that's done!” She shows me her lips and mouth. “Now I'll show you how Little Panda does yoga with me.” In front of the screen, she puts her head back and her feet in the air and then she puts the Panda doll in a similar position. “Now it's time to rest.”
As we approach the end of the session Sara continues talking, “Did you know that in 2nd grade I got an F and I cried? Okay, enough, now I'll sing.”
A: “When you sing, it may make you feel better for a while, but the sadness can still be there with you.”
Sara: “Do you know I'm good at inventing songs?” Sara begins to sing. “I love you, I know you, I love you, I'm naked, I know!” Sara stops singing. “I'm tired! Ah, it's 4:58. How much time do we have left?” Sara counts the time very quickly. “4:59, 5:00, 5:01, 5:02, 5:03.”
A: “By counting down the time, you are preparing yourself for the end of the session.”
Sara: “Okay, we have to say goodbye for good.” Sara closes the Skype and calls me again. “4:58, 4:59, 5:01, 5:02, 5:03. Hello!”
A: “Peek-a-boo! You're trying to get used to our being apart without completely disappearing when the session ends, and in this way you can feel sad and not simply throw your sadness away.”
Sara: “It's 5.00, 5:01, 5:02. We have to say goodbye.” She turns off Skype and she turns it on again. “Ok. Now, we really have to say goodbye.”
A: “Yes, now we really have to say goodbye.”
In this second fragment of a subsequent session, we see how the experience of her body contributes to the ongoing working-through of relational elements. Sara has demonstrated some initial ability to deal with space-time differentiation: for example, she has separate beds for herself and her panda doll. She is also aware of her body through the sores on her chin and in her mouth, which she can now represent and think about. She tries to look after herself by taking care of her sore chin with cream in the presence of her analyst and also by caring for her panda doll. Falling out of bed seems to represent Sara's anguish. Previously, she felt unable to control herself, but now, through her new-found awareness of her body and her body-mind relationship, she has discovered that her anxiety about falling is more tolerable. Sara's attention to her relationship with her body is further confirmed by her reference to yoga, and to teaching it to her panda.
As she approaches the end of the session, her anguish at being separated from her analyst emerges, along with her fear of being nothing, which surfaces when she speaks about her failure at school. Sara attempts to make herself feel better by singing a song about love. At this point, Sara's love for herself stems from a growing recognition of her own body: as she says, “I'm naked.”
Unlike previous sessions, in which the analyst had witnessed destructive movements and attacks, the end of this session is characterized by a countdown in which Sara records and contains her motor discharge (Freud 1911). This new ability to face the end of a session without complications was confirmed by her subsequent development, even after her return to the analyst's office.
Freud (, ) identified the mental link to the body as a main part of reality-testing and of the ego structure; Klein (, ) recognized in the body the roots of unconscious fantasy; and Bion (1962) saw the sensory plane as the origin of all abstract manifestations of thought, stressing the close interconnection of feelings and thoughts. The Italo-Brazilian analyst and theorist Armando Ferrari (2004) devoted himself to the study of the relationship of body and mind, considering the body as the original object of the mind. As we reflect upon the clinical material, we are especially reminded of Ferrari's double axis of processing: a body-mind ‘vertical’ axis and a patient-analyst ‘horizontal’ axis. These two ‘parallel’ axes of working through correspond, on the one hand, to the more traditional transference of the patient onto the analyst and, on the other hand, to the patient's internal body-mind relationship. This second body-mind axis and the patient's related transference onto the body (Lombardi 2017) are particularly important in approaching patients suffering from body-mind dissociation (Winnicott 1949; Goldberg 2020; ). It is precisely this axis that can step in when the analytic couple works remotely: the physical distance imposed by tele-analysis can stimulate the patient to recognize and develop the internal link with their own bodily reality, enhancing the working through of realistic space-time parameters and of the separation from the analyst in child analysis, and facilitating the analytic development during the pandemic, not unlike what can happen with adult patients. The limited nature of this brief clinical communication keeps us from enlarging further. Hence, we refer the reader to some of our earlier publications (Lombardi 2002, 2008, 2009, 2020).
We find this case to be a stimulus to reflect about where psychoanalysis is actually ‘at home,’ as a result of living in a pandemic age, in which we have given up inhabiting our offices, so as to continue analysis at a distance. It seems to us that the current emphasis on object-relationship theories and intersubjectivity has contributed to a disproportionate shift in the axis of reference of the analytic working through onto the plane of external relationships, thus causing the loss of the original emphasis of psychoanalysis on the internal working through and the relationship of the patient with herself. It might be worth asking if we aren't in danger
of throwing out the baby with the bathwater by disparaging a priori the internal relationship as old-fashioned one-person psychology.
Our aim in this article has been to stress the utility of working through the intimate interaction between the ‘horizontal’ analysand-analyst axis and the patient's ‘vertical’ body-mind axis—when working remotely in child analysis—together with the usefulness of favoring the vertical body-mind relationship. Here we can see how the elements of the first narcissistic organization derived from the recognition of one's own body (Freud 1923), activated by the analyst's orientation to work through the patient's transference onto her own body (Lombardi 2017), contributed to Sara's containment of her overwhelming anxiety.
The analyst's choice of intervention helped the patient to increase her perception of her own body as a springboard toward increased awareness of herself as a separate person, permitting greater containment of her anxieties, including her anxiety at separation from the analyst. Recognizing her own body implied that Sara no longer felt unbearable desperation when she separated from her analyst, because she now had an ‘envelope’ derived from her relationship with her body. It was represented at first through the form of the panda pajamas, which contained her. Sara then represented herself as her panda toy, a first form of spatial separation between her and her perceived self, which enhanced a maternal attitude toward herself. The inflatable mattress that Sara uses to protect her panda toy and herself from bumping into the wall could be regarded as the protective role of the development of an internal space, as well as a representation of the function of the analyst's reverie (Bion 1962), which helped Sara to tolerate the anguish and pain of the space-time limits connected to the discovery of her separateness (see also Migliozzi, 2019). Through the development of self-representation and specific attention to space and time parameters, time and space were no longer felt as infinite and uncontainable by the patient (; Lombardi 2015).
In conclusion, the elaboration of the body-mind axis shows itself to be a driving force in the activation of the patient's mental apparatus capable of attention and notation (Freud 1911, p. 220), making it possible to work through her overwhelming anxieties of disappearance and non-existence reinforced by the shift to remote analysis. As Sara approaches
the limitations of her body, she becomes more aware of space-time parameters and this helps her to contain her deepest anxieties, making way for the development of her ego resources. When she returned to the analyst's office, Sara seemed on the whole more integrated, and decidedly more able to be separated from her parents at the start of the session, and to say good-bye to her analyst when the session was over.