Anna Kudiyarova (Almaty, Kazakhstan). Psychoanalysis during Pandemic.

In this paper, I will discuss the challenges in providing psychoanalytical treatment connected with pandemic. There are transformations in form and content of the sessions. First of all, it is moving from offline to online individual sessions and emerging of online therapeutic groups. Then it will be increasing the themes connected with COVID-19. In this paper, I write about my own clinical experiences during the time of pandemics, about widening psychoanalytic frames during this anxiety ridden time.

The COVID-19 pandemic in Kazakhstan is a part of the worldwide pandemic. The virus was confirmed to have reached Kazakhstan on 13 March 2020.

On 15 March, President of Kazakhstan declared a state of emergency from 16 March to 11 May 2020. On 30 March, many cities were under a lockdown.

The reality forced us to respect ourselves. We could no longer see our patients and supervisees in person. We were faced with a choice: either to cancel and stop sessions by the unknown end of quarantine, or to switch to online sessions.

I was adapted to running the sessions via Skype for the last two decades, even more in 2013, I wrote the paper Psychoanalysis Using Skype. (1) Since then, ‘a lot of water has flowed under the bridge'.

At the beginning of quarantine, I used Skype because it was my tool for almost two decades. Now I have to switch to Zoom because of technical troubles. Skype was good for individual sessions but not group work. Everybody from a therapeutic group could change mode on Skype, not due to their resistance, but because they were just beginners and they didn't know all the rules of using Skype. Secondly, if someone had a bad Internet connection, all the group suffered from the inconvenience. Zoom was better because only the organizer could manage it. If someone had bad Internet connection, only he himself felt that discomfort, but the group went on without interruption. Thirdly, possibility to set up a virtual background, let run the sessions from anywhere: a kitchen, a hall, a bedroom and any consulting room while my room was being renovated, or a hospital if you get sick.

After thinking and rethinking, I prepared and sent a letter to every patient, every member of the therapy and supervision groups offering them online work. Almost all the individual and group patients have agreed to use the Internet. Then they received a new instruction of working online from me. (See attachment 1)

Even P., being an ardent opponent of online sessions, who refused for many years to use the Internet during my or her trips, gladly agreed to move to online sessions. We still joke about that new “desire” of hers. The pandemic helped her to be more flexible and to be prepared to the unexpected changes.

My long-time patients were already ready, they had previously worked with me online during my or their vacations. New patients and group members had to work on the technical aspects of the new mode. They set up Skype, Zoom, looked for a secluded room with windows and doors closed.

Due to the quarantine, usually the whole family was at home, it was impossible to ensure confidentiality and security. Sometimes I could see a child sitting next to his mother. The mother sometimes may warn me and stand up to change either pampers or a cartoon on TV. Sometimes our session might be interrupted by her husband, her mother-in law, her toddler etc.

In order to have more comfortable condition, some clients, who have a car, use their car. The interior of their car meet all requirements of our work, except at night time, when it gets dark and the client's face gets invisible. And here they find a way out: either they lit up their face with a flashlight, or move to another more illuminated place.

Being closed in studios or apartments, sometimes with no balcony, many patients were unhappy because they felt being cut off from cities' parks, streets, square, and just open spaces.

Some patients went to their parents' house in village or even moved there. In sessions they said, whether to buy a house in a village, or to start a farm business.

Moving to a village, of course, was an escape from social isolation, or maybe it was an escape from therapy, too. Because in some villages still there's no Internet.

There was always a way out for those who wanted to see me. For example, two of my patients were approaching a gas station by the time of the session, where there was Internet connection. Broken connection between us was also mentioned as a fact that they had to use only audio WhatsApp. There wasn't enough Internet power for the video.

There were a lot of anecdotes how a speaker was dressed below the belly during the online seminar. Yes, indeed, the same happened with me. As if my Super-Ego was getting less strict, sometimes, not always, because I could let me wear sport trousers with an office shirt. I would never dress in such way if I set in my own consulting room. Mostly, following the rules I forced myself to dress on as if I am at the offline session.

I guess it is the same with my patients. Some women could appear online in their dressing gown. Once a female supervisee turned up in her bath gown. Nobody said anything but next time she was dressed up in a usual way.

The first lockdown caused angriness; group members refused my proposal on moving online, except one participant. Perhaps, the reason was that participants were not ready for a sudden switching. Two months of quarantine they were silent, waiting for weakening of the quarantine.

All of them came back to my consulting room after cancelling the lockdown, feeling happy. Alive meeting in my office seemed as if the group members returned to the old world of accustomed communication face-to-face.

When the new circle of strengthening of the quarantine was announced, everybody from the groups quietly went online. Only one member left the group protesting.

Patient U: In the online group, I didn't feel people in the same as when they were around, when I could see them as a whole. Later, it seemed to me that even online group sessions turned out to be not different from offline ones.

It seems, not just this patient but many others preferred to feel and smell a person totally, not a part object.
In my turn, I was disappointed, too. Earlier I was absolutely against online therapeutic groups. I felt like a trapped wolf. I have heard that the wolf gnaws its paw to escape from a trap. Thus, he saves his live losing his paw. I had to save the group even though I could lose one of them.

Patient R: Now, when our cities do not have strict quarantine, during many online courses, or just communicating with people, I realized that I came back to the long-time forgotten skills to make friends with people from the first moment I have just met them. Maybe it’s because of the group therapy. We learn to meet new members, who join our group and I’m able to apply this skill in real life.

Even when my old groups rejected online mode of sessions, I got many requests from new people outside Almaty. I started seeing many online therapeutic and supervision groups. I had to compile a manual for online group work. (See attachment 2) So, pandemic changed my attitude towards group therapy running online. Now I have enough experience in providing online groups.

A new experience was to combine offline and online modes. If someone from the group was outside of the city, I let her to attend her group online when other members were sitting in the office. After a while I was subjected to cancel this form of working. It was inconvenient: the group members should speak louder than usual to be heard by online member, online member was partly seeing by offline members, someone was left out of the screen, it was impossible to see each one as in the consulting room. A shared virtual space was different from a shared alive space.

Some individual patients, too, refuse personal therapy online. As if they accused me in self-interest: Why to fear that virus? I am healthy, you have no cough, just you refuse to see me in the consulting room, then I will be the first to refuse. It's like they turned into babies who don't understand the pandemic and/or quarantine situation.

The denial of the pandemic, the crisis, I think, also manifested itself in the lack of talks on the ongoing reality. During the first two months of quarantine I noticed that my patients spent less time talking about pandemic issues. They were as usual preoccupied with their personal issues. That is the feelings and passions, desires for love, life and death desires that are shared in the transference between the analysands and me. As if my patients live dissociated from pandemic. As if they could not bear to acknowledge real issues. Any word about the coronavirus in the sessions might be mirroring of their denial and dissociation of the real situation.

But as if the reality in our city and country confirmed that absence: The total amount of infected people was 5000 out 18 million population, no one died before May 1. None of my patients or their relatives were sick, no-one was lying in the hospital, nobody died. The coronavirus was an invisible idea not a real danger for many patients.

After two months quarantine we were given more freedom. So, I met the demands of my patients and let them to come to the office as it was before the pandemic. Being the law-abiding one I created the additional Instruction for working offline to all the patients in our center. (See attachment 4) The new rules were set to keep in our office: regularly wash our hands and wipe surfaces beginning from the gates to the chairs.

In June, enjoying a short period of weakening the quarantine some patients went to the offices to work. Many patients went to shopping, to walking. Everybody breathed in freely. Unfortunately, the period of joy was very short. Since middle of June our country had an explosion of sickness and death.

In July, a new lockdown was announced in response to rising case numbers. Then this lockdown was extended to expire in middle August.

In August, the coronavirus cases in Kz are 104071, 1415 people died and 87920 recovered.

Since mid of June coronavirus and pneumonia cases toughed my patients and their family members. The patients actively discussed new facts of COVID-19 in the sessions. The explosion of virus and pneumonia triggered un/conscious defensive reactions, including obsessional cleaning, counterphobic behavior, and denial.

F (satisfied): My family now is very seriously prepared to COVID, yesterday we bought lots of vitamins and antibiotic drugs.

A: (surprised and angry) Just now? How about March?

F (carelessly): We thought COVID would avoid our family.

Seeing the unreasonableness, carelessness of my clients, I sent a reference to breathing exercises and the opinions of financial experts to prepare for the economic crisis.

The reality insistently came to my consulting room. I was subjected to move from the neutrality rule. I strongly asked clients to carefully calculate their finances, to have the money in stock for about six months, even better for a year to live on the same standard of living. I repeated that psychoanalysis is not a booby trap, first one must pay for the communal services and food. I explained that they do not have to live for the sake of psychoanalysis, on the contrary, psychoanalysis is for life.

Obviously, overwhelming affects generated by the real danger have led to regression. It seems to me, I take the role of careful mother either of my own worries, or due to projective identification from my patients. As if pandemic let me to weaken the strong rules of setting as it was accustomed before.

Our physical separation from our patients on working online during the pandemic doesn’t avoid moments of intimacy through a screen. The virtual presence of myself as a constant object allows for the patient to process and tolerate her distress, to share her doubts and concerns, anxiety and suffering.

I totally agree with a thought that 2020 is the Year of Anxiety. (2) Everyone on earth feels uncertainty due COVID-19, due experience of global quarantine of unknown duration, due financial crisis, due life that was very different to the one everyone had planned. Thus, now we have time of high anxiety. For sure, almost every patient would speak and show his/her fears and phobias.

One should have a certain amount of anxiety to survive, to maintain self-protective measures. The pandemic forced increased degree of health worries about oneself and loved ones, about jobs and the economy, the availability and deployment of needed resources, education. and advancement of their children, what life after pandemic will look like.

The members of one family manage the uncertainty that feeds anxiety in various ways. Some seek to reduce fears by consuming the latest information about the pandemic from many sources; others refuse reading the news. A sharp conflict may cause the stress when two subgroups in a family manage their uncertainty in opposite ways.

As everywhere, the globally imposed home quarantine of families has caused in-home conflicts and neurotic repetitions of unresolved childhood issues. Most of the thoughts I’ve heard during these months of the coronavirus pandemic: the Covid-19 epidemic is the result of human intervention; Darwin was right quite well; this virus is the consequence of climate change. My patients really were happy with that rivers have cleaner water, that they can see wild birds and animals on the city streets and parks. They blamed their relatives who behaved like ‘hooligans’ - didn’t sit home, visited friends’ parties/ceremonies that was the usual custom for Kazakhs.

Patient K (angry): I hate my parents. They live as of there is no virus, no quarantine. I yell yesterday at them when they were going to go a party by their old friend. Why? What for? They want to be infected and die!!
This crisis with its social isolation has revealed the matter of loneliness. Some patients of mine believed that they are not isolated as long as they have the social networks. But then they agreed that loneliness would not disappear due to social network connections, that moreover the messages, likes, smiles emphasized emptiness.

I am sure that psychoanalytical patients have the resources needed to face these challenges. They are not alone while seeing us, analysts. So, the flow of the new patients got bigger than before the pandemic.
Patient E (thoughtfully): An interesting point, just the pandemic prompted me to turn to a psychoanalyst faster, because during the isolation there was no one to share negative emotions with, no one to complain and those emotions began to eat me from the inside.

Psychoanalytic treatment helped my patients to overcome illnesses easier and faster. An example: a whole department of 7 employees got sick at once. They were hospitalized due to the very hard form of bilateral pneumonia. Just a patient of mine was recovered in 5 days. Others had been at the hospital for 2-3 weeks. One of them died.

In July, the theme of death was spoken often. It is obvious that deeper grief is processed after a death during pandemic where the usual rituals are prohibited — no burials, no big number of visitors. Traditionally, Kazakhs think the more people come to the ceremony the more respect to a deceased one. Sometimes there might be several hundred people. Nowadays officially no more than 10 people including medical and ritual staff may go to the cemetery. The patient H. complaint that just 19 people came to the funeral of her father. The patient J was disappointed because just mother, nephew and herself were allowed to go to the cemetery to bury her father.

The hypothesis on covered suicide? I have no statistics but it seems to me that some suicidal people use the coronavirus to end their lives. I have heard from my depressed patients sometimes: «I would like to get virus and die». Sure, we worked through such wishes. I concern that people with no psychotherapists can fulfill their death drives.

The group members, too showed anxiety and suffering in June and July when the amount of sick and died people got its highest point. Trauma needs to be integrated and that takes time. Psychoanalytic sessions give a space to speak.

Thinking and speaking what at times feels unspeakable, the members of groups came to find a way to make it bearable. They blamed pandemic, criticized politicians and mass media, the terrible state of our corrupted healthcare system, growth of the poverty and domestic violence. They were glad, that they were less vulnerable than others: elderly people, people at risk due to poverty and social conditions, that they have money not just to food and living but psychoanalysis. They felt sorry for those who do not have the resource of therapy during this pandemic.

Everyone experiences distress, despair, and anxiety in any time but the quantity of those feelings sharply increased in time of pandemic. For many, being stuck at home brought back feelings of an unhappy childhood, some became more conflictual, for others the social distancing became a desired state, and some were allowed for a personal growth through many free online courses. I believe our quarantine made many people kinder and caring for others. There is a hope that through psychoanalysis we face the unknown future being more confident.

Since the start of the pandemic we offered free online assistance to medical staffs in Kazakhstan. We offered a full schedule of webinars, consultations, supervisions for medical colleagues to support them at the unexpected pandemic affecting our world. It was an evidence of our team’s kindness and creativity. Our team struggled with our own responses to the COVID-19 and lockdown. Nevertheless, we had enough resources to help people to find new ways of living and working. As if we were one step ahead in challenging the transformation of family and social life. The reality required from our analysts’ team to offer to our medical doctors free of charge individual consultations. I personally didn’t see them but I run individual and group supervisions for those colleagues and students of mine who saw the doctors and nurses for free.

My supervisees have been challenged with increasing flow of patients. Many of supervisees have not their personal analysis by now. Usually, in so called peaceful years, a regular supervision group of mine consisted from 8 -10 supervisees. Now there are 30 people. Once a month I run a free supervision where there are from 40 to 60 participants.

I taught my supervisees to provide as secure holding and containment as they can. Theory of containment and holding again and again was recalled and applied in these crisis months. It became in a very high demand to contain and hold the experiences and feelings of patients, traumatized by COVID-19.

When the pandemic got its pick in July, we announced our readiness to see all the needy people for a very low price that was affordable for many poor and jobless people. We were confident psychoanalysis couldn’t be for free forever. Ones should pay for their inner work in order not to devaluate their own and the analysts’ work.

These pandemic showed that psychoanalytical knowledge and experience can be brought to the benefit of the local community through our psychoanalytic society. " As the president of IPA Virginia Ungarn said “It’s a time to value and be proud of our profession.”

References.

1. Kudiyarova, A. (2013). Psychoanalysis using Skype. In J. S. Scharff (Ed.), Technology and mental health. Psychoanalysis online: Mental health, teletherapy, and training (p. 183–193). Karnac Books.
2. Hara Marano. Repairing the Toll of Uncertainty. https://www.psychologytoday.com/us/articles/202007/repairing-the-toll-uncertainty

Attachment 1.
Instructions for online therapy session.

1. Privacy. Security. You must arrange a separate room/space with closed windows and a door. No one should overhear you or read your notes during a session.
2. Silence and concentration. Leave children/ toddlers under the care of relatives/nannies. Warn all family members (especially jealous spouses and babysitters) not to disturb you for 1.5 hours.
3. Insurance. Spare network sources. In case of power outage or sudden consumption of units, you should charge both your phone and computer in advance. It is desirable to use a computer, then you can see more, your hands are free, you can write in a chat if there would be some problem with voice. Your cell phone is needed for insurance, so you can quickly move from Wi-Fi to mobile communication. Put your cell phones on silent mode.
4. Prepare napkins (sneeze, cough).
5. Glass of water.

Attachment 2.
Instructions for online therapeutic and supervision group members.

Confidentiality of the material. Security. You must organize to yourself a separate room/space with its windows and a door closed. No one should overhear you or group members during a session.

Silence and concentration. Leave children/ toddlers under the care of relatives/nannies. Warn all family members (especially jealous spouses) not to disturb you for 2 academic hours. Put cell phones on silent mode.

Insurance. Spare network sources. In case of power outage or sudden consumption of units, you should charge both your phone and computer in advance. It is desirable to use a computer, then you can see more, hands free. A cell phone is needed for insurance, so you can quickly move from Wi-Fi to mobile communication.

Recording. Supervisees, be sure to prepare a keyboard, paper and pen. You will actively write answers to my questions and / or write down your thoughts for yourself to think about after a session.

Talk one by one. This means turning the microphone off all the time and turning it on only during your speech. Find the camera and microphone icons on your screen and learn how to operate them.

Prepare napkins (sneeze, cough).

Glass of water.

Attachment 3.
How quarantine influenced a patient of mine.

The first session offline after the lockdown and summer vacation.

P: Hallo.

A: Hallo.

P: (lies down, a short pause) I would like to re-tell you what I thought during the quarantine on my life. It is like a report how did I analyze while you were absent. It is obvious like in many people’s lives, the quarantine made changes in my life and psychotherapy as well. My primary source of income is the job in the office as you know. Beginning from April we were transferred to remote work from home and the company had reduced our salaries by 50 percent. Around this time, I moved to three personal sessions from four sessions per week as you recommended. Later, beginning from July I left only two sessions per week, because you increased the cost of sessions as you announced me some months before. You explained to me that you had been having another price for other patients for a long time as if you expected I would get angry. But I think it was quite fair and I accepted the rise of the cost without internal resistance. I heard once in your TV interview saying that the price of your sessions was a bit higher than I used to pay for 2-3 years. I think I even had a note of appreciation for you because for a long time I was allowed to pay old price despite regular inflation in our country.

I calmly accepted that I had to settle for two sessions because I had half of my salary and I couldn’t afford three sessions a week even if the increase in price was just slightly higher. Before as you remember well (laughs) I was inpatient of cutbacks of sessions but I have to admit that during quarantine it was amazing to me how calmly I accepted the new model of working with you. I think I was patient because the total number of my personal analysis sessions had reached 600 hours and it gave me a reason to be more patient. I said to myself: “Hey, at the end of the day it would be a shame to me if I overreact)))”.
Surprisingly for myself, I reacted to the salary cutbacks patiently while my colleagues displayed intolerance and even resigned from the job in that regard. I told you earlier it was very clear to me that due I did not have extra or passive income, I must hold on my job, whatever it is paid.

Nevertheless, this situation kept pushing me harder and harder to find additional skills and income. I believe thanks to psychoanalysis I already have my own ongoing dietary supplements selling projects. The quarantine and closure of stores in the cities has had a positive impact on my business because we adjusted to the online delivery of DS timely and made a good profit.

A: You are proud.

P: Sure. However, for now, I reallocate all investments in the second store and still do not withdraw my dividends. Therefore, the issue of other sources of income remains open.

As I know, we have discussed other sources of income at the sessions several times, but I preferred to stay “hungry” for sessions rather than to find new income. I think even this “hunger” had a positive moment because the value of the sessions opened to me differently. Before I used to lead a kind of idle life as a child and took the sessions for granted. Now, I feel the beginning of the time of consciousness. Please, don’t laugh at me. The reason why I think so is that after the quarantine in May, I finally managed to end my relationship with L. He is a man I had no future with. This breakup was the most painless one, despite I had only two sessions a week! Just online!! If anyone told me about it before, I probably wouldn’t have believed it. I cope!

A: You are proud.

P: Of course. And you know me. Even though I broke up with him after we lived together for 3.5 years, for whom I still feel gratitude and kind sentiments, I had no painful emotional outbursts even if I was in social isolation with you. (as if blamed me) While so many of my acquaintances and friends were breaking up, divorcing with scandal and mutual grievances, unable to withstand the quarantine.

In light of this, as I look back, I feel proud of myself, grateful to you, and to the man who invented the Internet. Yes, I want to dwell here on the topic of online sessions. Two or three years ago, I was very hard to agree to an online session and was constantly resentful of having to work online when you went going to another city or vacation. This time, instead of indignation, it was a humble acceptance of circumstances and even joy. Of course, in my observation, I have noted an increase in my internal flexibility. I was for a moment sorry and my past «hysterics» against online work seemed to be ridiculous.

A: As if you grow up.

P: Yeah. In general, I think I can firmly state that the quarantine has had a positive effect on my life, therapy and work. Despite the temporary, hopefully, financial difficulties and the reduction in the number of sessions, I had plenty of time to find new hobbies and interests while being on lockdown. I suddenly started thinking about financial literacy, and I discovered a lot of useful insights into finance. I was able to complete an online financial literacy course and it was a surprise to me that I already knew most fundamental things from working with you, from psychoanalysis. I passed all practical course tasks with ease and I was once again convinced of my leadership abilities. … (short pause)

The quarantine helped me to love classical music... with your help, of course. How? I watched your interview on YouTube. I became obsessed with ancient parables and wisdom following one of your posts on Instagram. Unfortunately, my special habit from an early age is that I used to walk around the house or down the street, or do any work with background music in my headphones. At one point, it made me nervous that I was listening to cheap pop or useless podcasts. But now I’m happy that even though I still have the habit of wearing headphones, at least I’m listening to useful things.

A: Or things that show we are like-minded...

P: …. Maybe. I go on with my report. When a lot of people were gaining weight being on quarantine, I was finally able to find a diet acceptable to me and get my body in order. And finally, thanks to the widespread online mode, I’ve resumed my Social Media Marketing training and I’ve already written up a business plan to launch extra income through SMM.

Now when our salaries have been restored, when I have more or less plans to improve my finances, I plan to resume three or even four personal sessions a week, and, certainly, not to stop my therapy for at least another year or more. Please, do not object me, I would not listen to you, sure, I remember your instruction that I must have deposit for one year to survive if the pandemic would last long time. Thanks to my working with you, I have learned to see the white eye by the black fish. (Ыhe means the Eastern famous black and white yin and yang fish)

I am happy to realize, the quarantine helped me to make crucial decisions and finally to move from words to actions. Hence, psychoanalysis helped me to get through the quarantine with ease and benefit.

A: Time is over.

P: Good-bye.

Attachment 4.
Instructions for working offline.

Please come out of the house wearing a mask and gloves. Open the gate and doors with gloves. In our psychoanalysis center, wash your hands thoroughly in the toilet before entering your analyst's consulting room.

If you have drunk water/tea/coffee, leave the used cup on the edge of the table.

After leaving the analyst's office, put on your mask and gloves again.

Take care of yourself and others!