“Si proche, si loin”. Changement de perspective dans les séances en ligne avec la famille

“So close, so far away” 

Change of perspective in online sessions with a family

Clelia De Vita^[*]

In this paper, I would like to share some thoughts on working remotely with a family, as the work triggered in me particular and recurring feelings of countertransference. Psychotic families tend to reproduce in the setting and in the transference the confusion and indistinction that are expressed in psychosis, which we can consider the center of a relational system in which many factors converge.

The family I refer to in this paper asked for my help after the psychiatric hospitalization of their twenty-year-old son, caused by an intense manic crisis in the previous weeks.

Since the beginning, the analytic work with this family has been characterized by the tendency not to respect the setting. From the first sessions, the boy or the parents asked me to change the time or the day of our appointment; the request, often motivated by the son’s difficulties in keeping in mind the time of the session, also came from the parents’ inability to organize. I accepted the family’s difficulties in respecting the setting as part of the functioning which tended to project confused infantile parts into the therapeutic container.

Since this starting point, the family’s ability to respect the setting has improved, allowing regularity in therapeutic work. Reflecting après-coup, I believe that the possibility of respecting the setting depended more on my willingness to accept the family’s various difficulties, including the request to meet remotely so as not to have to cross the city with traffic. This further request, which I initially considered part of the family’s attempt to manipulate the setting, turned out on the contrary to be a useful opportunity to look more closely at the family’s functioning. In fact, the family felt my availability to provide a virtual room as an authentic capacity to empathize. It seemed to me that my responding to the concrete difficulty of attending in person allowed the family to live in a “symbolic house” that kept everyone together through a unifying thought and gaze; at the same time, my availability enabled us to avoid gaps between the sessions, favoring the continuity of the work. The family’s difficulty in finding a stable home in therapy was linked to the prevalence of a confused and fragmented functioning, which was reflected in the presence of different houses between which the life of the members was divided (not really separated); many different spaces were used in a way which represented the psychological difficulty of integrating. The family history had reached a critical moment when the father had left home and separated from his wife. The son’s psychotic crisis had led to a new confusing closeness between father and mother, because the father was often present in mother’s house, with the excuse of helping his wife with their son’s crisis.

During the sessions, the family reported the son’s various movements from mother’s house to father’s house and the frequent escapes to the paternal aunt’s house. The continuous movements of the son seemed to be linked with the son’s search for closeness and emotional distance from parents: distance from the excessive closeness to the mother and from the emotional distance from the father. The use of the different houses was linked to some moments of transition in the therapy^[1] and represented symbolic passages in the relationship with parental figures.

The online sessions seemed to add a further house; what was already precarious in the face to face setting manifested in new complications related to getting together during online sessions. These seemed to increase the family’s tendency to disperse and to fragment. I couldn’t help family members to manage the camera to be all visible at the same time on screen; on most occasions, the family appeared fragmented into “different boxes”, because parent and son connected from different places. I found that the “dislocated setting” made me participate in the family’s fragmentation, exposing me to the same loss of mutual communication, just like a family member; the camera shots made visible the fragmentation, the loss of mutual communication and the absence of an “internal home” as a “nucleus”.

At the same time, the “remote therapeutic space” allowed the family to find a “symbolic house” that kept everyone together through a unifying gaze, responding also to the need to avoid gaps between the sessions. Even though they were displaced from each other in time and space, the members of the family seemed to find a containing gaze, coming together on the screen for the session.

Sometimes, in working with psychotic patients as a clinician, I find myself involved in a reversal of levels between conscious and unconscious, between manifest and latent. In the same way, it seemed to me that in remote work we could get closer to some crucial aspects of the family’s pathology.

In retrospect, I hypothesize that the mirroring, provided by seeing oneself on the screen, has become part of the therapeutic function; it has contributed to the creation of a representation in the family of “being a whole” and not just an aggregate of people.

Clinical flash

At the beginning of summer, the son had a new crisis and for days he took refuge at a friend’s house, escaping from his mother’s home (from the relationship with the mother, where moments of intense closeness alternate with strong conflict). The family friend, a psychologist, appears in the video and asks to address me as someone who is familiar with the family, explaining why the boy is at her home: he is persecuted by some ideas regarding his parents. Nando explains that he has been obsessed for several days by the (delirious) fantasy that his father is a demonic presence that wants to bring him back to mechanical functioning, while he is making an effort to save his soul. Nando is clearly confused because he received an antipsychotic shot in the morning, which made him feel very depressed; he collapses on the sofa, almost unable to stay awake.

The parents invite the son to speak about his feelings. He intervenes for a few minutes: “I feel like I want to get depressed, but my parents never accepted me getting depressed”.

The mother sits on the sofa, in bodily contact with the son, while the father stays to the other side of the video, sitting at a table, sometimes disappearing. They listen to their son’s words without saying anything.

I comment that “Nando told us a very important thing, it concerns the fear of depression, a fear against which you tried to defend yourself, finding strategies to survive, to cover loss and absence. I think that it is very difficult for you to stop in a place where you might think about what makes you feel bad. I believe that Nando is giving voice to something extremely important to all of you. It seems to me that you can’t respect the setting because you are afraid of the fear of break down”. In the subsequent sessions Nando is restless, unable to remain seated, he leaves the screen while accusing his parents of having ruined his life because he is incapable of growing up.

After the summer break, the family return to face to face sessions. Nando is still in a manic phase; He talks about his urgent need to go and live alone in an apartment by himself. Nando is very angry with his father, who had promised to buy him a small apartment, which he now claims as a condition for his well-being; he doesn’t give up on the fact that the father was unable to do what he promised.

The parents can’t contain their son and, following Nando’s delirium, speak about alternative and unsustainable solutions. Once again, I find myself facing the family’s dangerous tendency to implement concrete and inappropriate answers to the requests of their son, who is not yet able to support himself and live on his own.

But now, I feel that a new familiarity allows me to tackle previously unthinkable topics. We can share the idea that the home Nando is looking for is a state of Self linked with the feeling of staying safe within the family.

I comment: “The online sessions, by fragmentation and dislocation, had revealed to us how difficult it is for you to feel at home.  Nando’s request seems to correspond to the need to find a place where you can stop and develop a new way of being together. Nando is asking for a suitable home to grow emotions and thoughts”.  The therapeutic alliance makes it possible to talk about the importance of the therapeutic space as a new house, in which all the family members will be able to build the internal house, in which it will be possible to wait for the maturation time, not responding to the requests to leave prematurely (Nando was a premature baby). I comment: “I think Nando is expressing his need to renovate the family; for this reason, it is important to protect the therapeutic space, respecting the boundaries, to make it a safe container for changes in the family.”

The work done in this session helped Nando to give up the obsession of the house; over time, he was able to evaluate his own real possibilities and understand that, what he actually wanted was his father to give him the tools to grow.

Otherwise, the parents, scared to contact the reality of their son’s disorder, couldn’t tolerate the son’s anguish and deprived Nando of the possibility of developing his own solutions, proposing immediate and premature remedies.

It seemed important to me that, during an online session carried out at the home of a psychologist friend, it was possible to name the family’s depressive anguish and give meaning to the chaotic experience that the family was living through.

I think the screen served a protective function, thus bringing us closer to unthinkable anxieties.

A paradoxical change of perspective

The telematic sessions with the family involved changes in a precarious therapeutic situation, which led me to reflect on the meaning of what we were sharing. I asked myself: Who do I represent for the patient when I am on the other side of the screen? How can I use my psychological skills in this context? How is it possible to maintain the invariants of setting between face-to-face and online work? The countertransference is mobilized by immediate access to the patient’s intimate space, which entails a series of consequences and fantasies.

In the countertransference, I had to suture the family fragmentation and help them to participate and communicate via the screen. Despite the initial chaos, the online sessions made visible, in different camera shots, the family’s movement and changing of unconscious alliances during the therapeutic work, providing useful information for understanding the family’s functioning. It became another presentation card for the family. For example, the father’s dysregulation, or the maternal tendency to speak in place of her son, were highlighted by the disruption linked to distance among members and speaking through the screen. In some cases, the online session started with a view of the excessive closeness between mother and son in the absence of father, who was not visible on the screen. In other cases, the profound difficulties of communication between Nando and his mother caused outbursts of anger followed by the mother’s disappearance, as she disconnected before the end of the session.

In the phase in which the son got closer to his father’s house, in an attempt to escape from the maternal container, the mother conveyed her anger at the exclusion from the father and son couple.

Over time, I began to think that the remote setting offered a “paradoxical change of perspective”, consisting of the inversion between distance and closeness. The family connected from the dining table, from the sofa, greeting me as one of their own, giving me hospitality, welcoming me into their domestic environment; even the nonhuman environment became part of the setting, making me feel like a family member.

In the countertransference, I felt a particular form of intimacy that reminded me of my baby observation meetings, when I found myself entering the home of a family for the first time, invested as a professional figure. It evoked the earlier sensations arising from the intimacy with the family environment, such as had been established in the family where the baby was born.

I suppose that the change of setting into online sessions, had activated my (counter)transference towards the family, because I felt welcomed, even if only virtually, in the family’s environment, as in the times of my infant observation.

I found another “reversal in perspective” linked to the dualism between virtualillusion and presence-reality. consisting in the fact that the virtual dimension had made the real one more real. A central point of online sessions, consists in the fact that the therapist reaches the family members where they are and “where the family wants him to be”; in this way, the therapist supports the primary illusion (as Winnicott noted), a specific area of mental functioning, important for the development of the relationship with reality and with the other. The evolutive process, that Winnicott called found-created, consists in a paradox through which we become conscious of our existence and reality if we can share the primary illusion of creating reality.

I think that the online sessions had facilitated this evolutive situation, where I was a found created object”. Despite the fact that my presence was virtual, I became a “subjective object”, capable of supporting a change of perspective on emotional reality.

The found and created process is especially important for psychotic families, who can invest the therapist if he is not a too differentiated object. Session after session, my presence was assimilated by the family, becoming less foreign.

In this way, the online sessions allowed this family to find in the therapist a sensitive and welcoming parent, a figure who did not exist in the transgenerational family experience.

Unconscious fantasies mobilized by online scenarios

In the online meeting, the boundaries of reality blur, leaving space for a particular state of derealization, suspension, which represents the ideal condition for the reemergence of infantile fantasies, mobilized by contact with the family’s scenarios. The online dimension, in fact, favors “the pleasure principle to the detriment of the reality principle” (Freud, 1920) and, in this sense, promotes regression.  Early experiences are mobilized along curiosity and also childhood feelings of exclusion, relating to the primary scene. The intimate contact with the family will tend to re-awaken childhood fantasies and internal scenarios.

Even if the home sessions can be felt by the family members to be more supportive, thanks to the experience of primary illusion, at the same time, the online sessions risk becoming the realisation of a regressive desire, not just for the family but also for the therapist. For this reason, the therapist has to monitor his or her countertransference experiences and supervise them to be able to confer symbolic meaning to what happens in the remote sessions.

The family I have described, as others with similar functioning, tends to suck the therapist into an undifferentiated scenario, full of generational confusions, in which the therapist will find himself blinded like Oedipus, caught inside the network of the family’s pre-Oedipal and pregenital phantasma.

On the other hand, «the functioning of the psychotic’s family involves the existence of phantasmatic channels between the members who express representations of the other, of the relationship and of the group whose regressive character allows us to explain the patient’s disorder» (Eiguer, 1995, p.23).

Working with psychotic functioning, as Rosenfeld (1989) suggested, we have to enter the delirium to allow the patient to engage with the therapeutic experience, with the aim of bringing into the transference relationship what was previously projected into the inanimate object. At first, the therapist will have to accept the role assigned to him by the family, in an attempt to gain a path to change.

In the case described, the online setting created a particular form of closeness which accelerated the positive transference and the process of trust, based on feeling the therapist as less distant. The therapist has become a less extraneous figure because he has partially colluded with the psychotic functioning of the family.

Conclusions

The couple or family psychoanalyst does not only look at the unconscious contents but at what happens at various levels from the most superficial to the deepest, between individuals, at what unites them and articulates them both on the most superficial levels and on the most unconscious and profound ones (Nicolò, 2005, p.11). Some of these levels are made more evident by online sessions, which place the analyst in direct contact with the family environment and how it uses it. At the same time, the remote sessions deprive us of the sensorial level of the family. Also in the remote setting, sensations within the family link form a configuration, which revive traumatic feelings in a repetitive and paradoxical way (André- Fustier, 2009). If on the one hand the online session forces us to undergo sensory deprivation which could help to sublimate, on the other, the absence of containment provided by the therapeutic space can encourage regression.

The online sessions with Nando’s family made me reflect on the need to imagine the sensorial characteristics of the session, while when we are face-to-face, sometimes, we have to cope with the unpleasant sensorial expressions of the family, accepting to be affected and contaminated by them. The sensorial register is a useful trace for grasping implicit aspects of the family’s mental functioning; as with dreams, the sensorial register presents early sensory experiences, unthinkable aspects trapped in the body, which are waiting to access a symbolic and psychic transformation.

The condition of the analyst who encounters “the other in another world”, poses the problem of rules; it is not only therapy’s rules that he applies, but those of the medium that allows the connection. Derealization, amplified by the virtual medium, confronts us with a destructuring of boundaries with “role reversals”.

The remote session can work also without sensorial contact if the therapist can guarantee the same condition of suspension of concrete satisfaction. We must put reality between parentheses and give space to the internal world of the patient’s affections and experiences, giving prominence to psychic reality, with the same internal availability to welcome the patient as in face-to-face, with the emotional availability to tune in.

We need a “reversal of trend”, which requires a regression to contact the primary processes and places us and the family in the position of operating a “derealization in the service of the Ego”, which allows the prevalence of that illusional dimension, in which the “as if dimension”, typical of the illusion, can prevail. This is an important point for virtual sessions, that could reduce the reality principle in favor of the pleasure principle (Freud, 1920).

Virtual space, in its infiniteness, can find safety boundaries in the therapist’s internal setting, linked by fundamental rules for starting and maintaining the therapeutic process; in my opinion, the analyst finds himself in a situation similar to that in which he meets the migrant (De Vita, 2018): a strong connection with his own internal setting is needed in order not to get lost in a space without precise boundaries. The internal setting allows the analytic device to continue to function in virtual space: through compliance with precise rules, monitoring the role that the family assigns to us, making sure that the online does not coincide with an absence of limits.

Connecting to the internal setting, we could observe the variations given by the context; in this way, it was possible to experience a paradoxical aspect, such as “the change in perspective between closeness and distance”, extraneousness and intimacy, regressive and phantasmatic aspects, linked to inclusion in the family scenario.

Perhaps the screen introduces a “protective distance” which can make access to family intimacy easier; but there are many other aspects that we will be able to understand over time, reflecting on the therapeutic implications of the virtual context we share with our patients.

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“So close, so far away”  Change of perspective in online sessions with a family
Clelia De Vita

https://doi.org/10.69093/AIPCF.2024.31.06

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY).

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Bibliography

André-Fustier, F., 2009. Sensorialité en thérapie familiale. Le Divan familial, 22, 127-147. https://doi.org/10.3917/difa.022.0649.

De Vita. C. 2018. Migrant minds, Adolescent minds between eradications and radicalisations, Geographies of Psychoanalysis, Florence Congress, IPA.

Eiguer, A. 1995. La famiglia dello psicotico: nuove ipotesi, Interazioni, 1-1995.

Freud, S. 1920. Al di là del principio di piacere. In Sigmund Freud Opere, Vol. 9, Torino: Bollati Boringhieri, 1989.

Nicolò, A.M. 2005. Introduzione. In Quale psicoanalisi per la famiglia. Milano: Franco Angeli.

Rosenfeld, H. 1989. Impasse and Interpretation. London: Tavistock Publication.

Winnicott, D.W. 1968. On the use of an object. In Psycho-Analytic Exploration. London: Winnicott Trust.

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[*] Psychoanalyst, Full Member of ASNE SIPSIA Society; Full Member of the Italian Psychoanalytic Society; Graduated Child and Adolescent Psychoanalyst in Italian Psychoanalytic Association  ; Full Member of International Psychoanalytic Association (IPA); Member of PCF (Psychoanalysis of Couple and Family); Representer of PCF at SIEFPP and EFPP; Editor of “Interazioni”. cleliadevita1@gmail.com

[1] The mother’s house, in which the whole family lived, was sold recently because mother decided to buy a smaller one, with a large garden for the two dogs; mother’s old house was burdened by a persecutory experience for the son, due to the unpleasant sensations experienced in childhood and adolescence, but he also suffered from the change to the new house. During therapeutic work, the father separated from his new partner and decided to rent his own house, where he could host his son; before this step, the father had tried to buy a small apartment, hoping that his son could live  there on his own. Another important house is the maternal family house in a different location, where the family usually spent time in the summer. There is also a country house, bought by the couple in the past, no longer used, that was recently put up for sale by the father.