Technology, Transference, and COVID‐19 — With Reference to Davanloo's Intensive Short‐term Dynamic Psychotherapy – Wiley

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Corresponding Author
Catherine Hickey
Address for correspondence: [drcatherinehickey@gmail.com]
James Q. Schubmehl
Alan Beeber
Corresponding Author
Catherine Hickey
Address for correspondence: [drcatherinehickey@gmail.com]
James Q. Schubmehl
Alan Beeber
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The COVID-19 pandemic has had an undeniable impact on the practice of psychotherapy. Many psychotherapists made a rapid decision to convert to videoconference psychotherapy (VCP) early in the pandemic, but few had effective ‘how to’ instructions in the optimal setup of a VCP practice. Many psychotherapists find VCP to be convenient, practical, and effective in working in various psychodynamic modalities. But others have complained that the true intimacy of the emotional relationship of psychotherapy is lacking on the computer screen. This article seeks to define the optimal VCP setup in a practical way. We also review the literature to date on how technology impacts psychodynamic psychotherapy in general and transference in particular. We discuss the transference from the lens of Davanloo’s Intensive Short-term Dynamic Psychotherapy. We review the existing literature (both pre- and post-pandemic) on the effectiveness of VCP and note the paucity of empirical evidence (specifically randomized controlled trials) to support its use during global pandemics. Despite this lack of evidence, there seems to be enough anecdotal evidence to support that VCP is certainly better than no therapy at all, and in some cases, quite effective in maintaining the parameters of a highly charged and emotionally rich patient/therapist dyad. We support its use and anticipate future research.
COVID-19 has changed how the world does business. Psychotherapists have a unique perspective on how this single virus − and the resulting pandemic − impacted the human psyche. Indeed, COVID-19 has changed how we do psychotherapy. As professionals who work in a caring and healing field, we have been forced to adapt in many ways. We continue to work in some form but that form has been shaped by complex new forces − many of which are outside of our control. Some of us have been redeployed to work in other areas of medicine or counselling, others have been diagnosed with COVID-19, and many have lost loved ones to the illness. Those of us who provide psychotherapy have been required to greatly modify the way we do so. Some have continued with traditional office-based practice and have used Plexiglas barriers, protective masks, and hand sanitizer. These psychotherapists have embraced personal protective equipment (PPE) as the very real and physical armour with which they equip themselves daily. Others have volunteered to or have been required to do virtual care with patients. While the definition of virtual care varies from place to place, broadly speaking, it is the use of telephone therapy sessions or online sessions to provide remote care (Waddell et al., 2018).
While some have argued that virtual chats and psychotherapy apps should be included in the term ‘virtual care’, the authors feel that these technologies are beyond the scope of what many therapists have accepted as substitutions for being in person or ‘in the room’ with a patient. Additionally, while we recognize that many therapists offer sessions by telephone, this seems to have been a practice held long before the pandemic began. There may be a debate about having no visual image of the patient to guide the therapy session and, again, this is outside the scope of what we hope to examine. As such, we will focus our inquiry on psychotherapy offered by videoconferencing as this seems to be a ‘new normal’ adopted very quickly by psychotherapists throughout the world. We will use the term videoconference psychotherapy (VCP) to refer to this mode of psychotherapy.
The psychopathological forces that lie behind our patients’ symptoms and character problems have their roots in emotional traumas from the psychological formative years of life (Freud, 1917; Davanloo, 2005). The destructive impact on the patient’s current life persists because the feelings stirred up by the trauma are buried under layers of symptoms and character defences that have operated unconsciously. It is through the connection between psychotherapist and patient that the feelings from the trauma can be brought into a conscious experience so that healing can take place. Psychotherapy requires a focused bilateral interaction. Psychodynamic psychotherapy, in particular, involves an intense connection between psychotherapist and patient. In psychodynamic psychotherapy, the psychotherapist’s intervention is constructed based on the patient’s response, part of which is verbal but much of which is non-verbal. The receptive attitude of the psychotherapist is tuned into a range of perception in face-to-face therapy. Switching to electronic contact via microphones, speakers, cameras, and screens changes the perceptual field for the psychotherapist and the patient.
In VCP, the psychotherapist can no longer scan the patient’s overall posture, monitor tension in the hands and legs, or use olfactory data to sense hygiene issues. However, the detail is visible in the patient’s neurobiological state in the form of increased visibility of the state of the neck and facial muscles. It is therefore important to maximize these aspects of the interpersonal connection by careful attention to audiovisual (AV) media. This means engaging with the patient about the importance of establishing and maintaining an effective AV connection. The interactions involved give the message that the psychotherapist values the work and wants to set the stage to maximize the chances of therapeutic success. An optimal AV connection has a clear, well lit, face-on image of both psychotherapist and patient with a still, non-distracting background − similar to the face-on image of a TV newscaster. The voice is clear with no background audio distraction. When the psychotherapist and patient look at their screens, they should see the other with a sense of making eye contact in much the way that a good newscaster gives the impression that they are talking directly to you, the audience member. The psychotherapist and the patient will not have the same range of perceptual input as in a face-to-face encounter. The ability to visually scan the other is restricted to what is in view on the screen. For example, monitoring for the physical indicators of a discharge pathway of anxiety is limited because the image of the patient is usually going to be only of the head and upper chest; the psychotherapist cannot see one of the usual indicators of striated discharge of anxiety in the hands. At the same time, a well set up AV connection provides access to a strong sense of connection and many non-verbal cues that are more visible because of the detailed view of the other’s face. There is learning on conscious and unconscious levels in both psychotherapist and patient that usually grows into an increased sense of connection, with a fading consciousness of the fact that the manner of contact is remote AV.
The features of an optimal setting are the same as for in-person psychotherapy. They are the same for the psychotherapist and the patient. The room should be quiet and the setup should be one that is appropriately comfortable for the work of psychotherapy. There should be minimal audio and visual distractions, both within the screen and in view of the patient and the psychotherapist as they look towards their cameras. This means paying attention to ambient noise sources that one may not notice at baseline because one is used to them, for example, traffic, playground noise, etc. It also means coordinating with various aspects of life that could intrude, including, family, pets, and electronic devices.
Since remote AV connecting has been around for years, there are many programmes available. Skype and Facetime were two widely available early applications. There are now many others, and ‘to Zoom’ has become an expression for video connecting.
Dedicated medical visit oriented applications including Doxy Me, AMC Health, swy Med, Teladoc, and Mend are now available. A detailed review of the features of each of these programmes is beyond the scope of this article. In selecting a programme, one should consider the initial and ongoing cost of using the programme. The security features are important since confidentiality is required in medical and psychotherapeutic visits. The security features should meet local regulatory standards for security of confidential medical information. The programme should be user friendly so that the patient can easily download it, activate it, and join the psychotherapy sessions.
An optimal setup involves both patient and psychotherapist. Requirements for an optimal setup are a high-speed internet connection and a computer or tablet with a camera and a reasonably sized display. A headset with earbuds or headphones and microphone are optional, but can be helpful in compensating for unavoidable background noise or poor quality built-in microphone or speakers. A smartphone can be used, but the small screen diminishes the sense of connection.
The optimal visual setup has both patient and doctor seeing a large, well lit, face-on view of the other. It should be as if both people are sitting face to face, quite close to each other. Clothing with narrow stripes can cause a distracting moiré pattern visual effect and should be avoided. Background distractions, both stationary and moving, should also be avoided. The faces of the psychotherapist and the patient need to be adequately lit (see Figure 1).
At a minimum, lighting from a source in front of the subject is needed so that facial details and expressions can be seen. Optimal lighting includes two sources a little above face level, about 30 − 45 degrees from straight in front of the subject. This lights the face in a way that does not wash out details of the facial expression or create glare for the subject. The image is further enhanced if there is a light above and behind the subject, but no light source in direct view. Avoid bright light sources coming towards the subject from behind, such as an unshaded window, which causes the subject’s face to be underexposed so that details of expressions are not visible. It also creates a bright distraction for the eyes of the viewer. Eye contact can be optimized by using the following procedure (Personal Communication from Skorman M to Schubmehl J. 2020; see Figure 2).
The computer/tablet/smartphone is set up so the camera is directly in front of the subject and at or slightly above eye level. A line drawn from the middle of the screen to the eyes should be parallel to the floor. The built-in camera on most laptops is usually immediately above the centre of the screen, slightly above that line. Before beginning the meeting, the therapist should sit where they are when conducting therapy and look at the screen with their own face in view. The therapist should then move the camera, built-in or otherwise, so that the top of the display on the computer screen is a little above the top of their head and the bottom of the display is a little above their armpits. The therapist then looks directly at their own eyes and adjusts the camera angle by tilting the camera up or down and rotating it side to side until their face is in the centre of the screen and their eyes on the screen feel like they are focusing on themselves. It is important, and likely therapeutic, to work with the patient to establish a good video setup to maximize access to a strong emotional connection.
Poor audio quality can often be enhanced by the use of a headset with both earpieces and microphone (with or without noise suppression). This partially shuts out ambient noise that can drown out soft voices. Having the microphone close to the speaker’s mouth also helps their voice block out any background noise. If the patient or the psychotherapist is not comfortable with a headset and ambient noise is a problem, a unidirectional microphone placed as close to the individual as possible may help. A clip-on lapel microphone is another way to increase the volume of the voices and can also help mask any background noise.
For further advice on how to deal with VCP difficulties, see the recent discussion by Markowitz et al. (2021). His group notes the importance of turning off email and notifications, using an ergonomic chair, maximizing breaks between sessions, and minimizing other internet use when possible.
In March 2020 many psychotherapists adapted quickly to provide VCP, but few had the skills to optimize the contact. Subsequently, many psychotherapists engaged in a trial and error process and did their best to enhance the connection with the patient with whatever technology both had available to them. In this sense, COVID-19 has forced psychotherapists to accept a tremendous responsibility (Willan et al., 2020). Not only did psychotherapists continue to treat patients, they adapted to large-scale restrictions in the usual working environment and the need to protect themselves.
These restrictions have been widespread and systemic, necessitating adaptation in one’s personal and professional lives. On a professional level, psychotherapists have been expected to adapt to these many changes in a very short period. Those seeing patients in person have had to rapidly learn the basics of PPE. The availability of PPE has varied throughout the world and this disparity in availability has been a source of major stress for psychotherapists (Morgantini et al., 2020). They had to purchase PPE if in private practice or have had to obtain PPE from health authorities such as hospitals and clinics if they worked in a public system. PPE may provide a barrier to emotionally intimate contact, especially in terms of the subtlety of facial expression. For many psychotherapists, there was a rapid exodus from the accustomed physical office care provided remotely through virtual means. For some, this drive was innate and was the preferred mode of delivering care. For others, the impetus to provide VCP was external. The demand from employers or the need to maintain an income stream forced it upon them, often in a very rapid and disorganized fashion. Time did not permit a robust and comprehensive debate about the efficiency and effectiveness of using VCP as a primary means of treatment. Given that VCP can be delivered at home, some psychotherapists welcomed this change as they had been forced to provide childcare for children who could no longer attend school in person, and were, indeed, working themselves with virtual media. Our rapidly changing knowledge of COVID-19 caused unpredictability about the workplace, which was highly stressful for many. Despite no clear randomized control trial evidence to support its safety and efficacy during global pandemics, it was widely assumed that VCP was better than no care. Issues of patient abandonment and the risk of a long-term therapeutic ‘hiatus’ arose. But loss of psychotherapist income, employment, livelihood, and job satisfaction were also at play.
As well as the lack of clarity and unpredictability within their work environments, psychotherapists coped with psychological distress. Early on, frontline healthcare workers in China reported a psychological burden associated with caring for those with COVID-19 (Lai et al., 2020). Many countries grieved thousands of lost lives. Psychotherapists navigated the normal stages of grief associated with the deaths of loved ones. And they also navigated the grief associated with the deaths of patients and colleagues, the loss of income, the loss of productivity, and the loss of a normal professional and personal routine (Zhai & Du, 2020).
Despite these stressors, psychotherapists were expected to provide ongoing care for ill and traumatized patients; they were expected to provide care for children and elderly parents, and they were given less time and fewer resources to engage in the normal self-care that is needed to avoid burnout. All of this occurred on a background of fear that occupational exposure to COVID could result in transmission of the virus to their families and loved ones.
The human psyche can make or break transmission rates during a pandemic. This is because the disease burden is clearly shaped by the behaviours of each individual (Ebrahim et al., 2020). We are social beings and when in distress we can make decisions that gratify our need for contact with others by attending events that increase the likelihood of transmission. Stress leads to relapses of many pre-existing psychiatric disorders, including mood disorders. Significant psychiatric morbidities have been associated with other pandemics and these include anxiety, depression, panic attacks, somatic symptoms, post-traumatic stress disorder (PTSD), delirium, psychosis, and even suicidality (Tucci et al., 2017; Müller, 2015).
Stress can lead to poor self-care, substance misuse, and medication non-compliance, often because patients have lost their jobs and their incomes. A vicious cycle is created whereby the economic and social restrictions associated with the pandemic − clearly known determinants of health − influence the epidemiological rates of pre-existing mental illnesses. These illnesses can, in some cases, perpetuate the pandemic. Despite this fact, sufficient resources are typically not provided to manage pandemics’ effects on mental health and wellbeing (Duan & Zhu, 2020). While this might be understandable in the acute phase of an outbreak, when health systems prioritize testing, reducing transmission, and critical patient care, psychological and psychiatric needs should not be overlooked during any phase of pandemic management − especially as effective vaccines are rolled out.
Those with pre-existing non-psychiatric illnesses often experience relapses during pandemics. Psychotherapists should also anticipate development of anxious and depressive symptoms among people who do not have pre-existing mental health conditions, with some experiencing PTSD due to traumas associated with the pandemic.
The literature prior to the pandemic Prior to the pandemic, and in the last decade, most studies focused on telepsychiatry specifically (Hilty, 2020; Langarizadeh et al., 2017). Studies focusing more specifically on VCP were sparse. It should be noted that telepsychiatry in this setting would include other aspects of psychiatric care, including medication management and psychoeducation. As such, readers cannot rely on this literature to inform their care as it pertains to VCP, and more specifically, psychodynamic VCP.
Telepsychiatry has many advantages. It greatly improves access to care. It can be very convenient for both patient and therapist. Compared with other branches of medicine, it can be offered with no need for a physical examination or office equipment beyond an online computer. Pre-existing patient−doctor relationships can be preserved without significant interruption or infectious risk. Telepsychiatry has been previously used in natural disasters and has been found to be effective in treating psychiatric illnesses that have resulted (O’Brien & McNicholas, 2020). Given that insufficient access to care is one of the most important issues in addressing the mental health of a population, the Veterans Health Administration in the United States implemented a telehealth service that allows psychiatrists to treat patients either at home or at a clinic close to their home (Godleski, Darkins & Peters, 2012). In this context, at least four studies have shown that remotely linking a patient in one medical clinic to a clinician in another medical clinic has had positive clinical benefits in psychiatric treatment, and specifically in treating major depression (Fortney et al., 2007; Backhaus et al., 2012; Richardson et al., 2009; Ruskin et al., 2004). Similar benefits for patients diagnosed with PTSD (Yuen et al., 2015) have been noted. A 2016 review of 452 studies showed that telepsychiatry performed as well as face-to-face services (if not better) and that it was more cost effective (Hubley et al., 2016). Again, it should be noted that telepsychiatry refers to other aspects of psychiatric care and may include but is not limited to VCP.
However, there are disadvantages associated with telepsychiatry that are also inherent in VCP. Privacy concerns are paramount. Patients may not be alone in remote locations and instances of patients recording sessions without the therapist’s knowledge have been reported. Some clinicians have been slow to adopt such technology, citing concerns about video technology being insufficient for developing a therapeutic alliance as above and for detecting non-verbal cues such as tremor.
Other clinicians who have had some VCP experience, have voiced concerns about the complexity of learning the technology and understanding who exactly is responsible for providing support for technical issues. Concerns about patients not having appropriate and available technology have also been voiced. In her book, Screen Relations: The Limits of Computer-mediated Psychoanalysis and Psychotherapy (Isaacs Russell, 2015, p. 364), psychoanalyst Dr Gillian Isaacs Russell spoke of being hopeful that technology would ‘solve the dilemma of distance and separation’ and assist in bringing psychotherapy to remote places and isolated patients. Early on, however, she questioned if a highly effective therapeutic process could occur in the lack of a physical presence between therapist and patient, noting the importance of non-verbal communication between both. This is an important issue and makes the quality of the AV connection even that much more critical.
The literature since the pandemic Since the pandemic, several changes have been made to facilitate access to telepsychiatry services in the United States. Physicians can prescribe the full range of medications based on a telepsychiatry evaluation. The need for clinicians to use Health Insurance Portability and Accountability Act of 1996 (HIPAA) approved technology has been waived (Sheets, 2020). Such changes have resulted in a sweeping move towards telepsychiatry in the United States and some authors have argued that policymakers and administrators must now use this impetus to catapult VCP into the twentieth century (Kannarkat et al., 2020). The American Psychiatric Association has created a telepsychiatry toolkit with the intention to assist psychotherapists and psychiatrists in navigating this new world (Hilty, 2020). Large multi-site evaluations of VCP since the COVID-19 pandemic are not currently available.
Review of evidence/published literature on VCP and VCP psychodynamic psychotherapy, specifically VCP has been studied in some psychotherapeutic modalities. Internet-based cognitive behavioural therapy has been studied in various psychiatric disorders and found to be effective in depression and anxiety disorders (Andersson, 2009). One trial found that internet-guided psychodynamic therapy was helpful in generalized anxiety disorder specifically, but the authors note that the format was guided self-help, there was a high dropout rate, and no active placebo control group (the waitlist was used instead) (Andersson et al., 2012). Further research was recommended. Johansson et al. (2021) found that internet-delivered psychodynamic guided self-help was efficacious in treating major depression. Self-help is of course different from an interactive course of psychodynamic psychotherapy between patient and therapist.
Virtual versus in-person delivery of intensive short-term dynamic psychotherapy has been studied in medically unexplained pain (Chavooshi, Mohammadkhani & Dolatshahee, 2017). It was found to be most effective when delivered in person and benefits were maintained over 12 months. The authors of this study, published in 2017, commented on factors that may have limited the effectiveness of the internet-delivered therapy. Notably, maintaining eye contact was challenging as psychotherapists and patients weren’t always looking at their cameras. Seeing the full patient was also difficult, and monitoring ‘head to toe reactions’ was limited on Skype (as it would be with any online communications medium). In addition, one of the authors noted that approximately 30% of online sessions had some issues with connectivity, thereby limiting the sessions in both private practice and university sites. This study also focused only on patients with medically unexplained pain and cannot be generalized to patients with other psychiatric morbidities.
In April 2020, the American Academy of Psychodynamic Psychiatry and Psychoanalysis had a Zoom meeting with its members, under the auspice of the Psychiatrist Wellbeing Project, to discuss the impact of COVID 19 on psychotherapists, patients, and the work of psychotherapy in general. Several themes emerged, including paradoxical separateness, seeking an optimal interpersonal distance, finding new idioms, reality and symbolism, and loss, mourning, and isolation (Ingram & Best, 2020). It was noted that this early personal commentary would likely reflect ongoing themes as the pandemic progressed. That said, the content of clinical care was noted to be changed and one psychiatrist noted the conflict in values between herself and her patients as they all navigated life with COVID. One patient informed his psychiatrist that he had coached his children on how to lie to get a COVID test. The ‘surrealistic reality’ (Ingram & Best, 2020, p. 243) and the discussion of moral conflict gave a new focus to the here and the now.
In addition, in an email Q&A interview, Dr Gillian Isaacs Russell (2020) offered her reflections and insights on providing VCP in the pandemic. As a member of the American Psychoanalytic Association’s COVID-19 Advisory Team, she questioned: ‘Can a highly effective therapeutic process occur without physical co-presence?’ She further stated: ‘There has been a paradoxical drive to delete the body from the therapeutic interaction in the name of such things as convenience, democratization, continuity, and cost-effectiveness’ (Isaacs Russell, 2020, p. 365).
There is some literature on the impact of technology on transference published prior to the COVID pandemic. Kaluzeviciute (2020) noted that social media was increasingly being used to cope with anxiety, conflict, and desires. In classical psychoanalysis, there has been a tradition of therapist privacy and neutrality, and self-disclosure is used sparingly if at all. As a result, due to the absence of classical psychoanalytic therapists’ online presence, patients may seek to recreate psychotherapists on a virtual level (by means of online searching of the psychotherapist). This impacts the therapeutic space, as these psychoanalysts often do not know of the important material that is either known or recreated by patients through online means and, therefore, do not have the opportunity to work through such material. An important psychotherapeutic opportunity may be lost. Patients can construe extensive thoughts and fantasies about their psychotherapists based on what they see online. Such material can be a rich source of transference feelings which can lead to important unconscious meanings and discoveries. Gabbard (2001) notes the erotic fantasies that his patient ‘Rachel’s’ emails contained, and questions if such important issues in the transference would have been raised in the absence of the distance the online platform offered. Kaluzeviciute notes: ‘From this point of view, the Internet and the psychoanalytic session are both spaces in which people say or do things that they would not ordinarily say or do in real life’ (p. 313). Balick (2014) goes on to discuss a ‘virtual impingement’ and defines it as an online encounter encroaching on the in-person work of the consulting room. He further outlines that social media is neither inherently good nor bad, it just transports information more quickly and elaborately than ever before. Lemma and Caparrotta (2013) conclude that social media and cyberspace pose challenges to the assumptions psychoanalysts make on the setting and frame of their work.
This literature on the effect of technology and social media on transference discusses important theoretical and therapeutic questions. The pressing focus now is on the dramatic exodus of psychodynamic psychotherapy from the consulting room to the computer screen. Our discussion will focus on the rapid conversion to VCP. We will not be addressing non-psychodynamic therapies. Our focus is on the impact of VCP on both sides of the transference and countertransference relationship.
VCP poses challenges for both patient and psychotherapist. We will focus on our modality of interest − Davanloo’s intensive short-term dynamic psychotherapy (DISTDP) to illustrate this both theoretically and clinically. In order for the therapy to be both short term and intensive, the psychotherapist must utilize the transference relationship to collect data (the psychodiagnostic process) and to therapeutically alter the balance between resistance and the unconscious component of the therapeutic alliance. Successful therapy in Davanloo’s system relies on the predominance of affective responses over cognitive responses. To maximize these factors, the psychotherapy makes use of a close, emotionally intimate relationship with the therapist that activates feelings, and conflictual, often painful memories of the closest relationships from the past. There is a heavy emphasis on non-verbal behaviour and communication. Many patients have significant issues with emotional closeness that originate in traumatized attachments in early life. Defences against closeness in current life are reflected in the transference relationship with the psychotherapist. Avoiding eye contact is one example of this. Most certainly, the relationship to the psychotherapist is heavily affected by the absence of in-person, face-to-face contact, as is the case in VCP.
Nonetheless, if in-person, face-to-face contact cannot be achieved, understanding and applying principles of DISTDP can still intensify and shorten the course of psychotherapy. We present two case examples to illustrate challenges and solutiions.11 The clinical material for both cases has been fully disguised and consent was obtained from all patients/clinicians to use this disguised material in our paper.

Case 1.Ms S. is a healthcare professional in her 30s. She has longstanding characterological problems, symptomatic anxiety, and recurrent major depression. Suicidal impulses, precipitated by significant losses, have led to hospitalizations. Her father abandoned the family before her birth, leaving her mother overwhelmed with three young children. While she had suffered abuse by caregivers, her older sister had been emotionally, physically, and sexually abused over a long period of childhood. When her sister committed suicide, Ms S. was hospitalized with suicidal impulses. On discharge she was referred to Dr W., a male therapist with whom she became romantically involved. He abruptly terminated the relationship and was disciplined for his boundary violations. She again became suicidal and was admitted to the hospital. After discharge, she continued with the inpatient psychiatrist in psychotherapy. The work had helped her increase capacity to tolerate anxiety and the painful and terrifying feelings linked to her traumatic formative years and the emotionally linked events of her recent life. About three years into weekly psychotherapy, the COVID-19 epidemic necessitated switching to video sessions. Both Ms S and the therapist did not welcome the change. She expressed the fear that losing the direct contact of in-person visits would result in a loss of the sense of positive emotional connection with well maintained boundaries. This was important to the progress they had made. The therapist had fears about maintaining the sense of connection, but he continued to work with the patient, including addressing technical AV issues to maximize the connection. Several months after the switch to video she noted that the therapist’s eyes looked tired or bored. He has a mild degree of blepharoptosis which was more visible on video and accentuated by lighting and camera angle issues. In fact he was not tired or disinterested but her feelings brought up the transference issues from childhood of traumatic abuse and neglect, and the recurrences of these in her recent life. The therapist addressed the patient’s feelings of perceived abandonment. These were acknowledged and explored, leading to deeper working through of her original trauma and helping her to emotionally connect the transference reaction to the more recent traumas and the traumas of her formative years. He also educated the patient about the distortions of perception tied to the specific technical facts of VCP. The lighting on the psychotherapist was partially from overhead lights that cast a degree of shadow from his brow, thereby darkening the view of his eyes and lids. He also used a camera that was mounted on top of his display so that when he was looking directly at the patient’s image on the screen, he appeared to have his eyes more downward. The therapist both encouraged her feelings while also addressing the role of the realities of VCP-evoked positive feelings in the patient as it was different from the denial of the reality of her perceptions that had been part of her traumatic experience during her formative years. In fact, in a later session the psychotherapist himself was also moved by the patient sharing feelings about her early life trauma. She saw the psychotherapist’s eyes tear-up on the video and shared her feelings directly. This was possible both because of the ongoing work and the care taken to improve the AV connection.

Case 1.Ms S. is a healthcare professional in her 30s. She has longstanding characterological problems, symptomatic anxiety, and recurrent major depression. Suicidal impulses, precipitated by significant losses, have led to hospitalizations. Her father abandoned the family before her birth, leaving her mother overwhelmed with three young children. While she had suffered abuse by caregivers, her older sister had been emotionally, physically, and sexually abused over a long period of childhood. When her sister committed suicide, Ms S. was hospitalized with suicidal impulses. On discharge she was referred to Dr W., a male therapist with whom she became romantically involved. He abruptly terminated the relationship and was disciplined for his boundary violations. She again became suicidal and was admitted to the hospital. After discharge, she continued with the inpatient psychiatrist in psychotherapy. The work had helped her increase capacity to tolerate anxiety and the painful and terrifying feelings linked to her traumatic formative years and the emotionally linked events of her recent life. About three years into weekly psychotherapy, the COVID-19 epidemic necessitated switching to video sessions. Both Ms S and the therapist did not welcome the change. She expressed the fear that losing the direct contact of in-person visits would result in a loss of the sense of positive emotional connection with well maintained boundaries. This was important to the progress they had made. The therapist had fears about maintaining the sense of connection, but he continued to work with the patient, including addressing technical AV issues to maximize the connection. Several months after the switch to video she noted that the therapist’s eyes looked tired or bored. He has a mild degree of blepharoptosis which was more visible on video and accentuated by lighting and camera angle issues. In fact he was not tired or disinterested but her feelings brought up the transference issues from childhood of traumatic abuse and neglect, and the recurrences of these in her recent life. The therapist addressed the patient’s feelings of perceived abandonment. These were acknowledged and explored, leading to deeper working through of her original trauma and helping her to emotionally connect the transference reaction to the more recent traumas and the traumas of her formative years. He also educated the patient about the distortions of perception tied to the specific technical facts of VCP. The lighting on the psychotherapist was partially from overhead lights that cast a degree of shadow from his brow, thereby darkening the view of his eyes and lids. He also used a camera that was mounted on top of his display so that when he was looking directly at the patient’s image on the screen, he appeared to have his eyes more downward. The therapist both encouraged her feelings while also addressing the role of the realities of VCP-evoked positive feelings in the patient as it was different from the denial of the reality of her perceptions that had been part of her traumatic experience during her formative years. In fact, in a later session the psychotherapist himself was also moved by the patient sharing feelings about her early life trauma. She saw the psychotherapist’s eyes tear-up on the video and shared her feelings directly. This was possible both because of the ongoing work and the care taken to improve the AV connection.

Case 2.Dr A. is a psychotherapist who is learning DISTDP and is also in his own psychoanalytic psychotherapy treatment. About three years ago before the pandemic, the psychotherapist in training had a painful breakup of a romantic relationship initiated by his partner. He had just had a baby with his current partner. His infant was not sleeping through the night and he was regularly involved in night-time care. He reported feeling sleep deprived and worried about how this was impacting his clinical work in his training programme. He was also worried about his career after he finished his training, the end of which was rapidly approaching. In supervision with the author, Dr A. presented a patient who had previously been more engaged but was ruminating in a detached fashion. He volunteered to the supervisor that he had started to operate in a manner similar to the patient after his psychotherapy ceased to be face to face. He also noted that, like his patient, he was no longer making good eye contact with his therapist. This led to him and his therapist improving their AV setup and to focus on this transference issue with improvement in the work. He shared this outcome spontaneously with the supervisor.

Case 2.Dr A. is a psychotherapist who is learning DISTDP and is also in his own psychoanalytic psychotherapy treatment. About three years ago before the pandemic, the psychotherapist in training had a painful breakup of a romantic relationship initiated by his partner. He had just had a baby with his current partner. His infant was not sleeping through the night and he was regularly involved in night-time care. He reported feeling sleep deprived and worried about how this was impacting his clinical work in his training programme. He was also worried about his career after he finished his training, the end of which was rapidly approaching. In supervision with the author, Dr A. presented a patient who had previously been more engaged but was ruminating in a detached fashion. He volunteered to the supervisor that he had started to operate in a manner similar to the patient after his psychotherapy ceased to be face to face. He also noted that, like his patient, he was no longer making good eye contact with his therapist. This led to him and his therapist improving their AV setup and to focus on this transference issue with improvement in the work. He shared this outcome spontaneously with the supervisor.
Mobilizing and maintaining the optimal emotional intensity is likely to require modifications of technique, including work on the nature of the differences between VCP and in-person psychotherapy. Emotional intensity, though somewhat limited by the remote AV setting, can still reach the level necessary to mobilize the unconscious forces of the therapeutic alliance and of the necessary affective responses. This is evidenced in Davanloo’s training workshops (Davanloo, 2015) in which experienced psychotherapists are interviewing each other, using Davanloo’s techniques, while other participants are observing in a neighbouring room via closed-circuit monitors. It is quite common for observers of this intense process to themselves experience breakthroughs into their own unconscious, often with heavy affective responses and vivid memories. The supervisor, as part of the workshop experiential learning experience, then processes this. It is also quite common during DISTDP symposia, group teaching, and supervisory activities and video demonstrations and courses of DISTDP, that participants experience mobilization of their unconscious in a similar fashion. These processes are facilitated by the setting and emphasis of the various formats. In the clinical setting, mobilization of the unconscious in VCP can be facilitated by one or two in-person, face-to-face sessions if safe and feasible. Even without the face-to-face sessions, mobilization can be achieved with the proper application of Davanloo’s techniques by applying the maximum pressure within the patient’s capacity to tolerate anxiety and painful affects; and thereby removing resistance in a single setting, sufficient to breakthrough into the pathogenic core of the unconscious and begin the process of multidimensional unconscious changes.
The unconscious of highly resistant patients can be a sophisticated saboteur of the therapeutic process (Beeber, 1999) and can utilize aspects of the therapeutic setting in the service of defeating the process. Psychotherapists, too, may unconsciously collude with the patient to keep the intensity low (counter-resistance against emotional closeness). For example, before the pandemic, patients/psychotherapists may have had remote VCP sessions for ‘convenience’ when in fact the real reason for the request or offer is to reduce the emotional intensity. This could be understood as a variation of what Davanloo called tactical defences. This may also be seen in ‘messing up’ the placement of the camera or microphone, to reduce the emotional intensity of the session. The psychotherapist may resist developing and implementing the skills needed to set up and operate an effective AV system and to instruct the patient in doing the same. The psychotherapist may also resist addressing issues with the patient’s side of the connection.
Once the pandemic resolves sufficiently, patients and psychotherapists might want to continue remote video sessions rather than initiate or resume in-person, face-to-face therapy. This may be a function of resistance (or counter-resistance) against emotional closeness. Similarly, reduction in the frequency of sessions, or setting chairs at an angle to reduce direct eye-to-eye contact, may also be a function of resistance (or counter-resistance) against emotional closeness.
Despite the shortcomings and limitations outlined above, DISTDP can still be quite helpful in the absence of in-person sessions. It can be used in a VCP format in patients who are already in an ongoing DISTDP treatment, who already have shown a significant degree of mobilization of the unconscious, and for whom the treatment would otherwise have to be prematurely terminated. The early experience suggests that VCP can be effective even with new patients, but the need to attend to the transference issues must be kept in mind and addressed on a moment-to-moment basis.
Earlier in his pioneering work in short-term psychotherapy, Davanloo utilized other techniques of therapy that were quite useful in mobilizing the unconscious and leading to symptom reduction and characterological change. His earliest work focused on short-term dynamic psychotherapy (STDP; Davanloo, 2005), which was still at that time revolutionary. It relied on an interpretive style of focus on the transference relationship (the current technique does not utilize interpretation) and the link among past/present/and transference (the TCP link; Menninger, 1958). Other techniques involved a two-stage unlocking of the unconscious by first mobilizing grief laden feelings, and then in a second stage, attempting to access pathogenic unconscious guilt (Davanloo, 1990). Yet another technique, the ‘gradated technique’ was adapting for patients with a relatively low capacity to tolerate anxiety and who manifested anxiety in the form of autonomic discharge of anxiety and symptom formation. In this approach, the unconscious was accessed over two or more sessions in a stepwise increase in the patient’s capacity to tolerate anxiety and painful affects, such that ultimately a breakthrough into the pathogenic zone of the unconscious might be achieved (Whittemore, 1996). He devised another approach called ‘crisis intervention’ based on his mentor at Massachusetts General Hospital, Eric Lindemann, for accessing the unconscious in patients who were either in the midst of a major crisis (such as the death of a child) or were suffering from a form of pathological grieving. While today, Davanloo would say that these techniques are outdated, they were considered highly effective at that time.
DISTDP is a highly effective psychotherapeutic technique whose hallmark is an intense, emotionally close, and intimate relationship with a therapist, who working collaboratively with the patient, mobilizes the constructive forces in the unconscious for symptom reduction, multidimensional unconscious structural changes, and characterological change. Though there are many potential pitfalls, video DISTDP may provide valuable psychotherapeutic experience in these very trying times of the pandemic. Many psychotherapists who trained with Davanloo have also utilized peer supervision in small groups as an adjunct to their training, where they review video recorded sessions with colleagues. In this circumstance, given the pitfalls, peer review of AV recorded sessions can be extremely valuable, in addition to one reviewing sessions by oneself.
Psychodynamic psychotherapy values transference, countertransference, and the emotional intimacy that comes with overcoming resistance. When a psychotherapist and a patient are in the room together, there is an implication of a conscious alliance to work together to overcome the patient’s suffering in life. Being in psychodynamic psychotherapy specifically, however, implies an unconscious choice to work together. When the unconscious therapeutic alliance between patient and psychotherapist comes into play, the deeper work of therapy can happen.
This article sought to answer the question: Can VCP be, in any way, an acceptable substitute for in-person psychotherapy during the unprecedented time of a global pandemic? In the absence of robust empirical evidence including randomized controlled trials, we feel that the answer is yes.
While some have practiced virtual psychotherapy for a number of years, many have had the experience of their first virtual visit with a patient at the onset of the pandemic. Many have navigated a bad internet connection, a clumsy office setup, and a less than ideal sound system. The psychotherapist has been challenged to develop the new skills of setting up, operating, and teaching the basics of setting up and operating an effective AV connection. The psychotherapist must further learn to observe a different set of perceptions and to integrate those perceptions with the reality of the AV connection into their technique.
Optimally, in those first moments, as both patient and psychotherapist overcome the obstacles they faced in connecting, when there is the first eye-to-eye contact, many feel the sense of hope that is part of any good psychotherapeutic relationship. In an established in-person therapy that is converted to virtual, there is relief that the psychotherapist has not abandoned the patient. There is relief that the patient is still alive and healthy enough to do the work of psychotherapy. There is a recognition that the previous work was important and that, while there is more work to do, it will be possible to do it. Regardless of whether or not in-person sessions had transpired previously, many patients find solace in the fact that emotional help is even available during the pandemic − a time of true physical distancing and isolation.
The recognition that accompanies such a connection is the very essence of psychodynamic therapy (Alexander & Morton French, 1980); that despite the obstacles and hurdles, both patient and psychotherapist − like an effective parent and child − want to work together to form an alliance and attachment, in this case, to heal the wounds of the past and gain emotional freedom.
Marvin Skorman assisted with the development of this manuscript. There was no financial support for this manuscript.
CATHERINE HICKEY has 17 years of experience as a clinician, educator, and researcher. She is a psychiatrist in Canada. She received her MD from Memorial University of Newfoundland in 1999. In 2004, she completed a psychiatry residency at Dalhousie University. She completed a psychosomatic medicine (medical psychiatry) fellowship at Harvard University (Brigham and Women’s Hospital) in 2005. She commenced a traineeship with Dr Habib Davanloo (founder of Davanloo’s intensive short-term dynamic psychotherapy) in 2004, and remains active in his Closed Circuit Training Workshops to this day. She is an Associate Professor at Memorial University and is involved with teaching along the continuum. She is the author of numerous peer-reviewed publications and the textbook Understanding Davanloo’s Intensive Short-term Dynamic Psychotherapy: A Guide for Clinicians. She is recognized as a mentor for learners and won the Association of Chairs of Psychiatry of Canada 2019 Award for Excellence in Education. Address for correspondence: [drcatherinehickey@gmail.com]
JAMES Q. SCHUBMEH MD is a Clinical Associate Professor of Psychiatry, University of Rochester School of Medicine. His education was at University of Notre Dame, University of Virginia School of Medicine, Case Western Reserve University, and Bronx Municipal Hospital Center of Albert Einstein College of Medicine Psychiatry. He had three to seven weeks of training and supervision annually by Dr Habib Davanloo in Davanloo’s intensive short-term dynamic psychotherapy (DISTDP) between 1984 and 2015. He has extensive clinical, administrative, and management experience in community mental health and in private practice in Bronx and Rochester, New York. From 1977 to 2018, he was the organizer and director of the Rochester Institute for DISTDP. He was on the editorial board of the International Journal of Short-Term Psychotherapy from 1995 to 2003 and Co-Editor from 1998 to 1999. He currently teaches a 12-week course on DISTDP at the University of Rochester and provides weekly individual supervision for residents. He has presented in a variety of academic settings on DISTDP, including full-day courses at the annual meeting of the American Psychiatric Association.
ALAN BEEBER MD is Professor Emeritus in Psychiatry at the University of North Carolina (UNC) School of Medicine in Chapel Hill. His medical training was at the Medical College of Virginia, and his residency in psychiatry at the State University of New York Upstate Medical University in Syracuse, New York, where he served on the faculty of psychiatry for two decades. He joined the faculty at UNC in 2001 as Professor of Psychiatry where he is now Emeritus Professor. His most recent area of practice has been in Psychosomatic Medicine/Consultation-Liaison Psychiatry and in Intensive Psychotherapy. He was in training with Dr Habib Davanloo for over 25 years. His publications in Davanloo’s intensive short-term dynamic psychotherapy (DISTDP) include such topics as Davanloo’s concept of the perpetrator of the unconscious, Davanloo’s new metapsychology of the unconscious, the history of DISTDP, and transference neurosis.
As this was a review article, no data were generated for statistical analysis. A copy of the literature review can be made available upon request.
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