Pandemic psychotherapy: how does the relationship dimension change?

Pandemic psychotherapy: how does the relationship dimension change?

First introduced in 1127, quarantine is the main contrast measure adopted during all pandemics of infectious and contagious diseases. Already in the past, literature has placed emphasis on psychological distress related to pandemics such as increasing levels of anxiety, panic and distress in the population or changing the perception of risk and the modalities of transmission. 


Corona Virus Diseases 19 (COVID-19) is a respiratory disease caused by the SARS CoV-2 virus. Emerging in China in December 2019, it quickly spread to all continents, prompting the WHO (World Health Organization) to initially declare the emergency state of international public health and, in March 2020, the pandemic state. The latter is characterized by the presence of a new virus with a proven human-to-human transmission, by a universal susceptibility, i.e. the absence of antibodies in the organisms, by a serious health impact and by a worldwide spread with significant risk of restrictions on trade and to international traffic. The mode of transmission is by respiratory route or by relatively close contact. At the moment,

Contagious diseases have been an integral part of the history of humanity since men began to organize themselves in society, creating nuclei of people who relate and coexist in the same space (Panè, 2020). From the Black Death of 1300 to today, numerous pandemics have been recorded, the most relevant of the last century are the Spanish flu in 1918, the Asian flu H2N2 in 1957 and the swine flu A / H1N1 in 2010.

First introduced in 1127, during the plague epidemic in Venice, quarantine is the main contrast measure adopted during all pandemics of infectious and contagious diseases (Brooks, 2020). Despite medical-scientific progress, social distancing, characterized by the confinement and limitation of social relationships, is still the main response in the presence of new epidemics (eg SARS in 2003, Ebola in 2014).

Already in the past, literature has emphasized pandemic-related psychological distress such as increasing levels of anxiety, panic and distress in the population (Wong, 2010) or changing risk perception and transmission patterns . Furthermore, further negative psychological effects, recorded in the restrictive measures of the past quarantines, were: increase in suicides (Barbisch, 2015), increase in manifestations of anger or lawsuits, presence in the population of depressive symptoms and symptoms of post stress disorder – acute traumatic (Brooks, 2020), avoidance behaviors (towards people with symptoms or public places) and / or overprotective behaviors. These changes have continued for a long time even after the pandemic ended (Lau, 2010), the longer the quarantine period,

The current pandemic situation, characterized by a perceived constant danger of life, the uncertainty of being able to be treated in the hospital, the fear of the potentially infected other, the reduction of freedom of movement, the deprivation of the mourning process, physical separation from loved ones, the emptying of warehouses and the difficulty of finding medical safety devices, the sudden economic crisis, the uncertainty with which institutions and nations move, can produce dramatic effects on health and is configured as a peri situation -traumatic which can have a strong impact on the central nervous system.

Porges defines neuroception as

The perception of danger tends to activate more ancient defense reactions, such as mobilization or immobilization, attributable to the “reptilian” brain, or more evolved, such as the tendency towards social engagement, connected to the “limbic” brain, up to the development of a shared sociality and morality (Churchland, 2012).

During a pandemic we find ourselves in a condition of threat to life that is shared by the community, but is experienced by individuals or families in substantial social isolation, as a condition that leads to an inevitable limitation of co-regulation. In a context of social distancing, the activation of the reaching out (search strategy of the other relative to the “mammiferous” defense of the cry of attachment), pushes us to maintain at least virtual connections with our fellow humans, the use of a video calling allows us to perceive the interlocutor’s voice and facial expression.

However, this activation may not prove sufficient for co-regulation and may also blow up the “social pact”, that is, the rules, rules and expectations underlying our daily living and our sense of security.

This could have an impact on the alarming nervous system which, not having the concrete possibility of activating social involvement, would tend to present hyperactivation of the most ancient animal defense systems.

In our patients, but also in all of us, in fact, we can notice behavioral tendencies to flee (e.g. get out of the rules) or attack (intense anger towards the institutions or towards the conspecifics that are approaching) or even phenomena of immobilization attributable animal defenses such as freezing (paralysis, insomnia, panic attacks) or collapse (hypersomnia, hypo-activation, tiredness, lack of motivation for action). Of course, each person will react based on their life history and internal operating model (Bowlby, 1973).

The attempt, as psychotherapists, is to regulate the nervous systems of our patients, so as to transform the peritraumatic situation into an opportunity for expansion of both awareness and the ability to manage one’s internal states and the sense of helplessness experienced.

The psychological intervention in the emergency field has, in fact, peculiar characteristics that differentiate it from the ordinary one, so the application of the psychological and psychotherapeutic skills, typical of the clinical setting, needs to be adapted and integrated with the knowledge of emergency practices and online services (CNOP, 2020).

In the presence of a pandemic, with the emerging psychological need on the one hand and the limitations in being able to practice the profession with traditional methods on the other, what are the aspects that distinguish the psychological intervention and the therapeutic relationship?

The spread of Covid-19 has inevitably led to a change in the therapeutic setting, the introduction of software for video calls, through which to carry out clinical interviews, has in fact transformed the session into presence into an e-therapy experience. This phenomenon, for some psychotherapists, has not been entirely new, in light of an already previous diffusion of computer, synchronous (video calls) and non-synchronous (messages and e-mail) means.

This rapid operational change was motivated by the situation of potential danger, by the need for mutual protection and protection and was aimed primarily at the continuation of the therapeutic work already set previously (CNOP, 2013), with particular caution with respect to subjects with difficulties in the examination of reality, suicidal ideas or serious dissociative states.

This important revolution in the therapeutic setting leads to numerous clinical reflections.

First, the pandemic places, perhaps for the first time in the history of psychotherapy, a patient and therapist in the same peritraumatic situation, a condition that generates a sense of shared helplessness and vulnerability and at the same time promotes empathy and compassion. Through online psychotherapy, the opportunity emerges to share, in the here and now, one’s human experience. Our houses open to each other, allowing us to access, through the screen, the daily places of the other. The visible spaces of intimacy favor, paradoxically, greater closeness than the physical presence in the usual setting. In this clinical context, the therapist’s awareness and attention to their self-disclosure and responsibility towards their well-being are even more important.

Online psychotherapy also requires the therapist to pay more attention to non-verbal communication, which takes place mainly through the patient’s own face, to be constantly monitored, in a parallel process, with continuous adjustments (light, distance from the screen, direction of glances, etc.).

Mutual effective communication and the orientation of the patient’s attention to his / her own bodily signals promote the reinforcement of the adult Self and the mind-body integration.

The loss of part of proxemics remains an embodied experience of impoverishment in the relational process; however, the possibility of observing one’s face in interaction with the other activates mirror neurons and facilitates reflection on one’s emotional and mental states, opening interesting points of contact with Self Mirroring Therapy (Vergatillo, 2020).

A further element to be taken into consideration in the online context is the possible instability of the Internet connection: the occurrence of breakages and repairs of the communication tuning, which takes place through the network, can be considered as “the objectification” of what happens daily to the within human communication and in the attachment relationship. The authentic mutual commitment and the experience of repeated repairs to the loss of communicative synchronization favor the capacity for emotional regulation and offer an interesting parallelism with an experience of secure attachment: mothers who break up following an effective repair, have more capable children to regulate (Tronick, 2008).

We can also consider the “online disinhibition effect” (Suler, 2004), which highlights the tendency of individuals to express themselves and act with greater impulsiveness and emotional intensity on the web, rather than in person. The shield between the individual and the online world creates a barrier that can be experienced as protection.

In this case, web psychotherapy could also facilitate the patient’s emotional expression, promoting access to more intense emotions in the therapeutic relationship. In fact, there is a greater availability and openness of patients to the identification and sharing, in the therapeutic dialogue, of their deepest suffering nuclei.

We therefore hypothesize, considering the clinic of the disorganized attachment, that the activation of the attachment system can be experienced as less “dangerous”, given the physical distance and the potential greater control by the patient in the relationship with the therapist (eg. person could easily choose to interrupt communication), and thus encourage the regulation of attachment phobia. At the same time, the possibility of maintaining the relationship through the web, despite the common pandemic situation, could instead favor the regulation of the phobia of the loss of attachment. In fact, the therapeutic relationship becomes the space of care that can be preserved, but at a potentially less “threatening” physical distance. This hypothesis could enrich the clinical reading compared to the work with the parts of the Self, which on many aspects, appears facilitated and more effective in online psychotherapy. The dyadic dance (Schore, 2008) of the therapeutic couple with respect to the attachment relationship seems to be more fluid at times, thus also facilitating the relationship of the adult patient with his own internal experience. This confirms that psychotherapy can be considered a “corrective relational experience”.

When working with internal systems in the clinic, following the guidelines of Ego State Therapy (Shapiro, 2017) and / or Theory and of the intervention with Structural Dissociation (Van der Hart et. Al., 2006) , we proceed to the identification of the “parts of the self”, which can be more or less dissociated, so as to increase their awareness and therefore also the regulation and management in daily life.

From a clinical point of view, these “parts” can be traced back to neural circuits that preserve life experiences, memories, memories and are bearers of emotions, intense sensations, and recursive thoughts. The nervous system tends to protect itself from this intensity, developing “defenses” that maintain internal separation and fragmentation. These defenses can be called “phobias”, a term that can include a sense of rejection, fear, drive to exclude and / or eliminate these aspects of the self from one’s daily experience.

The survival mechanism, which saves the brain in acute situations, remains active even after the danger has passed, continuing to exclude parts of the self from the consciousness (emotional, somatic and / or cognitive), which further intensify their implicit experience by forcefully entering the patient’s experience, who is forced to re-experience these memories, although he is committed to excluding them from consciousness (Baita, 2018).

In psychotherapy we learned to work with phobias, in other words the psychic defenses that protect the patient’s daily functioning, through the progressive approach with EMDR (Gonzalez and Mosquera, 2016), also including the precious clinical indications of Janina Fisher (2017) and Robin Shapiro (2017). The most effective strategies can be summarized in promoting the dis-identification of the person from what he feels, proposing to consider this intense experience as a part of himself. This is done by trying to represent it with an object, a drawing or a mental image, to then be able to work on the relationship of the adult person with this part of his internal system. The goal will be to promote recognition, curiosity, awareness, understanding, empathy,

We note that the online mode not only maintains the effectiveness of these therapeutic tools, but tends to increase their effect. We hypothesize that physical distance, and in particular the exclusion of certain senses, such as touch and smell, can make people experience a greater sense of safety even compared to the therapist as another potentially dangerous “mammal”, especially for who has gone through complex trauma stories. It seems that this may facilitate adult regulation (clinically associated with the activation of the prefrontal cortex) and in some way reduce the intensity of phobias towards internal states, which allows for a more immediate, rapid and effective work.

Furthermore, the use of the image of the patient himself, which is available on the various video call tools, can also be used as a resource for the recovery of the Adult Self and the presentation of the parts of the self, offering the patient to look at himself and to recognize himself in your present image.

The use of objects belonging to the patients’ home, and therefore more familiar to them, seems to favor the empathic connection with the internal experience; the possibility of proposing an experimentation with respect to the distance from that object seems to promote an active and autonomous management of the object itself, which could give light to a deeper sense of empowerment in the daily management of intense sensations and emotions or recurring thoughts. It seems that patients find themselves doing more work to keep themselves adults, while bringing the therapist into their homes and therefore closer, but in a condition of complete control of the means of communication, as already highlighted.

Furthermore, the possibility of experiencing psychotherapy directly in the spaces of the patient’s daily life, could facilitate the consolidation of functional therapeutic relational experiences (eg adequacy, mastery, protection, regulation), which do not thus remain confined to an “other” space than everyday life, as can be the study of the therapist.

We do not know exactly what the factors are at stake, which certainly vary from situation to situation, but in general we note how this type of work of distinction and connection often gives results of emotional and somatic regulation more effective than the usual work of in vivo sessions. People frequently report feeling more integrated, managing their daily lives better, and accessing central areas of suffering with less difficulty. As therapists, we more easily have an overview of our patients’ internal system. Of course this does not apply to all clinical situations, but in general we can go on to speculate that online psychotherapy work with ego states and parts of the self has unforeseen benefits, to be explored, continued to explore,

The pandemic, exposing us to the lack of physical and economic security, to forced isolation and social estrangement, to the fear and stress related to the uncertainty of the future, urges, as already highlighted, our alarm system continuously and, in some cases, this situation can reactivate and re-open old pains, increasing the risk of emotional disorganization.

It is therefore important to contrast the sense of helplessness found in the states of peritraumatization, the feeling of being dragged into a situation, involved in a state that stimulates the implementation of defensive automatisms to have the opportunity to experience a sense of mastery deriving from to feel that we are actively participating in a great shared experience (Van der Kolk, 2020).

The words of Jon Kabat-Zinn, a molecular biologist who contributed to the spread of mindfulness in western culture, are extremely useful to guide us in this historical moment, when he defines pain as

while suffering like

and therefore one of the possible responses to physical and emotional pain (Kabat Zinn, 1990).

Mindfulness is a self-observation practice that leads to a gradual greater awareness of oneself and of the reality in which we live; it is a way of being in interconnection, relationship with oneself, with others and with the world, with an attitude of curiosity, friendship, welcome, openness, letting what resonates, in a non-judgmental way. This practice develops starting from constant care dedicated to universal human qualities, innate transpersonal intentions such as kindness towards oneself and others, compassion, the ability to rejoice with and for others and equanimity, that is, availability and ability to go to every moment of life with equal respect and sensitivity.

The cultivation of both formal and informal, individual and group mindfulness or inserted within a therapeutic path has proved, even during the pandemic, a valuable practice, an important tool for the elaboration of suffering. In fact, it favors the integration process at the basis of psychophysical well-being, at different levels: intrapsychic, interpersonal, social and connection with the world.

Meditative practices can help:

Even in pandemic times, starting from what is our present, anchored to a sense of internal security, is important to maintain the possibility of choosing and acting in the direction of the future.

This article was born from the comparison between psychotherapists who have experienced, for the first time in human history, the experience of their work in a pandemic context.

In the face of an impoverishment given by the impossibility of a relationship in presence, our flexibility and adaptability as human beings have allowed the therapeutic relationship to go beyond social distancing.

The sharing of clinical reflections has revealed unexpected and surprising advantages, prompted us to conform and co-build new therapeutic modalities and tools, but requires further study and research developments on medium and long-term efficacy.