March 2021 marked the one-year anniversary of our collective response to Covid-19, giving us an opportunity to reflect on our experience with, among other things, tele-supervision by video conference and phone. Changing in-person supervision of in-person treatment to tele-supervision of tele-treatment was difficult, particularly for those of us who supervise child analysts and therapists, and for our supervisees. Most of us were short on experience with, and long on prejudice against, online work. Having to change how we supervised and treated patients overnight made the work even harder. However, Covid presented us with a crisis. Supervisors and supervisees rose to the challenge and learned new ways to work. Many of us defended against the harsh reality of Covid-19 by thinking it wouldn't last long. As the terrifying sprint became a depressing marathon, we learned more about the essence of analytic supervision.
During analytic training, many candidates and trainees absorb a set of assumptions about what analysis is and isn't. These are often delivered as bedrock truths by our teachers and supervisors. Such assumptions, handed down from one generation to the next, are often presented as self-evident truths that need never be questioned. In fact, not questioning them may be a way to solidify our professional identity as analysts—at least for some. For example, we are taught and then we teach: You can't do tele-therapy or tele-analysis because therapist and analyst must be in the same room with the patient. Likewise, we assume that, in order to teach effectively, supervisor and supervisee must be in the same room. These assumptions imply that tele-supervision of tele-treatment is impossible.
As absurd as that may seem now, many of us learned that to be an analyst we had to accept such views as facts; some of us may still believe them. Nevertheless, I think such views pose major obstacles to providing good and responsible supervision, especially when the supervisor and supervisee are in different rooms.
We should ask ourselves: Are we currently telegraphing to our supervisees that tele-work can be psychoanalytic, that is, it can reveal wishes, fears, conflicts, and transference-rich material? That, in their training and their education, it counts toward work with control cases? That however different it may feel, remote supervision is not necessarily worse or better than in-office work? Or are we communicating to our supervisees that tele-work isn't real, won't count, and merely provides a holding pattern until we get back to true in-office work?
I believe tele-analysis and supervision can be conflict- and transference-rich. Alternately, it can be a stilted pretense of treatment or supervision. How effective it is depends on the analytic or supervisory pair and how they deal with the very real challenges of a remote session. In-person therapy or supervision can also be real or it can be stilted. Whether two people meet online, over the phone, or in person is only one of many variables that influence the quality of analysis and supervision.
However, we should not pretend that tele-treatment or supervision is the same as in-office work. To do so is to deny the sense of loss we may experience in a video conference or phone session. Calling attention to how these sessions are different than in-person meetings and mourning the differences when necessary are better ways of making tele-sessions work. Although I prefer in-office work, I infer that most pairs find tele-analysis and distance supervision in some ways the same and in other ways different, in some ways better and in other ways worse.
To insist that a pair must be in the same room in order to be psychoanalytic and effective may be a way of avoiding mourning the losses wrought by Covid. Avoidance may protect us from painful feelings but limits our ability to adapt to Covid and post-Covid realities. Even for those of us lucky enough to circumvent Covid-related loss and illness directly, we have all been confronted with fears about the health, capacity to work, and finances of our loved ones and ourselves. We continue to experience anxiety about the future of our profession.
There's an old saying: Analysis shouldn't be defined by the furniture. Perhaps Covid will teach us that therapy and supervision should not be defined by an office or the physical distance between us and our patients and supervisees.
A mere two years ago, it was inconceivable that we would be supervising candidates and trainees who had never sat in the same room with their patients, their analysts, or us. It still seems like a science-fiction-meets-psychoanalysis fantasy. Perhaps the impossibility of this new reality explains why some people avoid mentioning, in supervision and treatment, Covid or their experience working online or by phone.
Yet, it's crucial to help supervisees think about what is lost when they do not share concrete space with their patients. In the office, because both are
Daniel W. Prezant, Ph.D., is a Training and Supervising Analyst for adults, children, and adolescents at NYPSI. He is in private practice, the APsaA Membership chair, acting chair of the Covid-19 Advisory Team, and the ACT secretary.
actually there, therapists and patients face the possibility of kissing or killing. Those who defend against this fantasy online or over the phone may also defend against recognizing the power of other libidinal and aggressive impulses. During Covid, the real prospect of infecting or even killing each other may make the exploration of these fantasies too terrifying. But when there's no chance of actualizing wishes and fears—to hurt and to love—it may protect the patient and the supervisee to the point of deadening the analysis.
Supervisors can also teach supervisees to attend many other aspects of online treatment, including but not limited to silence, privacy, the frame, technology, and intimacy.
Supervisees may need guidance to understand online silence. Silence can be hard to tolerate and harder still to understand in any type of session. Online, it's more difficult to recognize cues for taking turns and, therefore, to know when to speak without speaking over the other. It's less clear whether the patient is thinking and/or defending against uncomfortable feelings, especially in a phone session. Cell phone pauses can be so quiet that it's hard to know whether you can't hear the other person, they can't hear you, or that the call has dropped. Supervisees also struggle with what to do when they can hear a patient speaking but can't make out many of the words.
Supervisees may need permission to think about the effects of meeting from home with their patients and with their supervisor. In the office, it is the therapist and supervisor who create and maintain the frame. In our offices, we know how to ensure privacy and confidentiality. There, patients are not likely to show up in their underwear or pajamas or barefoot. (Nor is the therapist, for that matter.) They typically don't enter our offices seconds after being in work or family meetings. They also can't enter another Zoom meeting seconds after getting up from our chairs or couches. They don't talk to us from the toilet. They aren't cooking or eating meals, parenting, or doing laundry or work for their jobs. They're not looking at multiple screens, shopping online, watching porn, masturbating, or encouraging their partners to listen or join in.
In other words, working remotely means the frame that holds analyst and patient, and supervisor and supervisee, becomes a shared responsibility. Supervisors can work with supervisees on when to interpret such forms of distancing as a defense or when to give patients guidelines for how to behave in a tele-session. Once there's been a breach of the frame, the supervisor can help the therapist think about it analytically as well as practically.
Supervisors can educate supervisees to recognize how defenses may appear differently online than in person. Supervisees may be too anxious or inexperienced to notice that patients who complain about technology may be displacing complaints about the therapist and Covid onto video glitches. On the other hand, patients who are positive about online work might be defending against feelings of longing and absence, abandonment and neglect in regard to the therapist.
Working remotely from home—inviting the other into one's home—can resemble in-person home visits in which patient and therapist might become over-stimulated and overstimulating. This new intimacy can amplify voyeuristic and exhibitionistic fantasies that can feel exciting, seductive, shameful, and aggressive. Patients, therapists, supervisees, and supervisors likely have wishes and fears about showing our more naked selves and our families. Transference wishes may be defended against with fears of intrusiveness, acting out, Zoom disinhibition, defensive withdrawal, and fatigue.
Many patients, when working from home, worry that they're being overheard during their sessions. Supervision offers the therapist the opportunity to think with the supervisor about what this might mean and what, if anything, can be done about it. Early-career clinicians may not see how this worry can inhibit the patient or, on the other hand, encourage exhibitionism. Patients may not be able to secure a private space at home, but they may also be unconsciously encouraging their partners or children to eavesdrop—and enact a primal scene fantasy. When patients bring their analysts into their home online, it may stimulate transferential fears or wishes of betraying their spouse with their analyst and betraying the analyst with their spouse. In a parallel process, the supervisee-analyst can feel excited and uncomfortable entering into the supervisor's home online.
Psychoanalysts and therapists may defensively resist seeing the intense positive and negative transferences, sexual love, and aggression patients sometimes show us online when family members are close by. Supervisees may feel ashamed or guilty if the patient's spouse or parents see how much the patient loves and hates the analyst. In such cases, the therapist's discomfort may lead to resistance in affect or hinder a full analytic exploration. Patients, their parents, or partners may pick up on the supervisee's resistance and double down with their own. When both the patient and the supervisee are too uncomfortable with certain feelings, it can interfere with the analytic attitude, an outcome that lends credence to the belief that online analysis cannot be analytic or transference-rich.
As ominous as the transferential complexities of tele-work may sound, they are best dealt with by the same curious and non-defensive analytic attitude that we typically bring to in-office work. Supervisees may need to know that voyeuristic
and exhibitionistic wishes and fears are fundamental elements of work in the office, online, or on the phone before they can notice it, let alone interpret it. If candidates in analytic training, for example, ignore anything they see and hear on the screen or phone that differs from what they experience in the office, in order that it be considered “real analysis”—and in order to avoid shame associated with voyeuristic impulses—they will likely resist bringing such experiences into supervision.
Another challenge during Covid is that patients, therapists, supervisees, and supervisors are dealing with similar feelings at the same time. Knowing this can help clinicians foster greater empathy for their patients. This, however, can also interfere with the distance an analyst needs to remember that, even though this is a very real event, most of us react in characteristic ways that reflect our singular histories, transferences, wishes, fears, conflicts, and defensive patterns. In ordinary times, supervisors guide supervisees to understand that such real-life matters as fees and schedules simultaneously serve as defensive displacements. Now, we need to guide supervisees to recognize that Covid, the computer screen, and the phone are realities that also function as defenses against the therapist and more.
Supervisees are anxious about how Covid and tele-treatment will affect their training and their income. How do they get control cases, accrue licensing hours, or earn money if remote work doesn't count as part of their training, or if their patients—or the parents of child patients—are out of work? Many are concerned about getting new patients when they're working only online or on the phone. It's one thing to adjust to remote sessions with an ongoing patient but a very different thing to begin online. Supervisees may unconsciously compensate for the distance by being more active, more passive, or more self-revealing.
Beginning analysts may need help seeing how resistance to therapy can get amplified online. Imagine a very resistant adult patient in a negative transference who becomes even more resistant online and insists on ending treatment. With supervision, the therapist might see the patient's wish to terminate as it functions as a defense against the patient's anger. This could be anger at the therapist for not protecting him from Covid or about the shift in the frame. On the other hand, it could be a defensive maneuver to avoid the excitement and fear that might accompany being in the analyst's home and having the analyst in his home.
Alternately, it's possible that this very resistant adult becomes more engaged in tele-analysis. We might support the supervisee as he comes to understand that, for some patients, physical distance brings a sense of safety and freedom that allows them to experience more aggressive and sexual wishes toward the analyst. New awareness of these wishes might terrify the patient. We can imagine that a patient who came to his in-person sessions reliably might now express such terror by forgetting appointments, or having persistent problems connecting with his computer or phone. We can encourage the supervisee to consider how missed sessions might actually indicate progress.
We should ask ourselves: Are we currently telegraphing to our supervisees that tele-work can be psychoanalytic, that is, it can reveal wishes, fears, conflicts, and transference-rich material?
What about the countertransference? Do our supervisees become more judgmental in the countertransference when they feel anxious about their own survival? Deprived of basic familiar rituals and comforts in their lives, or angry about their own powerlessness in relation to so many changes, therapists contend with their own emotional experiences in this new analytic frame.
Supervisees may not see that their own fears, anger, and guilt are interfering with their empathy for adolescent and adult patients who, for example, refuse masks and vaccines, or gather without keeping physical distance, or who report touching, kissing, or having casual sex. When supervisors help their supervisees feel more contained, they likely will develop greater empathy and understanding. After all, Covid-19 brings a cruel contradiction to a young person's developmental need to assert autonomy, push away from their family, deny their vulnerabilities, try out their sexuality, and move from the family group into their friend group.
Likewise, supervisees may not see how their own fears about Covid could interfere with understanding why a phobic adult or child patient sees the pandemic as an answer to their prayers. Not only do they get to stay home and avoid what they're afraid of, including their analyst, but everyone encourages such avoidance.
The anxiety that supervisees might feel can also make it harder to be empathic with the child or adult patient who wants to meet only in person, or agrees to a tele-appointment but resists engaging in the analysis. These patients may assert that nothing is wrong—they have no worries about Covid and don't care about any of the changes in their lives. Supervisees may need support in recognizing a patient's need to rigidly deny their fears to protect themselves from being overwhelmed.
So how do we adapt to tele-supervision and help our supervisees adapt to tele-treatment? Over 15 months, most of us have been able to adapt relatively well. At the core of our work is the recognition that patients' conflicts, transference, and resistance will usually surface regardless of venue—whether it's in person, online, or on the phone. Many of us find that patients and supervisees who were working well in the office continued to do so online or on the phone, whereas patients and supervisees who were tenuously connected,
or had trouble working in person, had even more trouble with remote work.
Thus, what we do at a physical distance is very similar to what we do in person. We try our best to teach supervisees to create video or phone environments that feel as genuine as possible while encouraging them to be open and honest about how different it may feel from working in person. We look at the reality as well as the singular meaning of Covid and tele-treatment for each patient. Although the world has changed, hopefully our analytic ability to understand the patient and the treatment remains the same.
Regardless of the venue—online, by phone, in the office—we support the people we teach to track changes in their patients' talk, play, and affect as signals of psychic pain. And we guide supervisees to track their own feelings in the countertransference that might foster a better understanding of their patients' psychic lives. We also help the supervisee maintain the alliance with the parents of their child patients by discussing additional pressures parents have experienced during lockdown and will feel as the world opens up.
We came a long way in the first not-so-short year with Covid. When you're in an ongoing history-making experience, as we are (or hopefully were, depending on when you read this), it's hard to predict what the future holds, but I think we still have a long way to go. The normal we're all hoping to go back to will likely exist only in the history books. As vaccination rates increase and Covid cases decrease, we still have to consider whether and when it's prudent to go back to our offices. And there may be other reasons besides safety to continue online or on the phone with certain patients and supervisees.
In this new normal, we and our supervisees will make choices about if, when, and how to reopen our offices. Analysts and analytic therapists are not typically directive. Even if we and our supervisees only ask patients to be fully vaccinated before meeting in person, it's still directive. All the more so if we or our supervisees ask patients to prove they're vaccinated, wear masks, pass Covid symptom checklists, and not use waiting rooms or bathrooms. In the new normal, some will refuse vaccinations, some will be too young to get vaccinated, and some may be too immunocompromised to develop immunity.
In the new normal, some supervisors, supervisees, therapists, and patients may choose not to do in-person work. Some may choose not to do remote work. Institutes might require candidates and trainees to do in-person work only. Insurance could stop or decrease reimbursement for tele-therapy.
If, or when, we go back to in-person work, we will think about how to work with supervisees and patients who don't want to come to the office. Surely, this will be influenced by our own beliefs about what constitutes effective supervision and treatment as well as our own beliefs about being directive. Making these kinds of decisions will come more easily to those who have strong convictions. However, some of us are uncertain about what will be best. For some, the choice might depend on what seems best for particular patients or particular circumstances.
At the core of our work is the recognition that patients' conflicts, transference, and resistance will usually surface regardless of venue—whether it's in person, online, or on the phone.
Trainees and candidates will benefit from talking with their supervisors. It may be difficult for supervisees to tell their patients that they no longer work remotely when they've been working that way for over a year. It may be useful to consider whether to announce a rule of treatment or interpret the desire to continue online as a resistance that needs to be understood so that patients can let themselves have the best treatment.
For those who choose to continue distance work along with in-person treatment, supervisors and supervisees will have to change their focus from assessing the patient's analyzability to assessing in what venue the patient is analyzable. At this transitional point, it's hard to know what type of analytic or supervisory pairs would be the best fit for tele-work, which would be good enough, and which would be simply undesirable.
Looking down the road, I anticipate that few of us will go back to seeing supervisees and patients in person only. Many of us will use a hybrid model where we work sometimes in person, sometimes online, and sometimes on the phone. This will likely lead to many practice and analytic challenges. We will have to help our supervisees think about whether they should require their patient to work in a particular venue or let the patient choose. They will need to think about what to do if a patient disagrees with a supervisee's recommendation or doesn't seem to be able to make a choice. We can encourage supervisees to contemplate why an online or phone patient might show up in person to surprise the therapist—is that an enactment of a primal scene fantasy? What about the in-person patient who suddenly wants to call or go online—is that a matter of convenience or a move to catch the therapist off guard?
If supervisees see patients back to back and use a hybrid model, it could be challenging to navigate from in-person to phone to online. Supervisees might have to contend with not quite knowing if they need to go to their waiting rooms, turn their ringers on or off, or log into or out of their online platforms. A supervisee may be waiting for their patient to show up in person and not notice that the patient is calling or waiting online, or vice versa. Given our long-forced isolation, it seems good that we are at a point where we can think about these possibilities. And it's especially good that such possibilities and their implications can often be worked through between supervisor and supervisee.