Making more from less in a Corona encircled analytic frame and Situation

Ken Israelstam
Presented at the open day of APAS conference. September 2021.

At the start of this pandemic, I was confronted with an awful never- to- forget image seen on  TV, of an electron -microscope view of the spiked virus, greedily devouring human lung  tissue. Like all parasites, it cares nothing of suffocating us to death, as well as caring nothing  of sucking the life force out of our crucial analytic frame and situation . This frame, like our 1 vital organ the skin, is alive in holding the emotional bones and tissues of the analytic  encounter together. Like our skin, it is a crucial boundary between the inside and outside  world, and when functioning well it’s alive, containing and activating, firm yet flexible. When  attacked it loses its firmness and resilience. I hope to demonstrate how when this sense of  safety was lost, a parallel process, a specific anxiety, was activated in both myself and my  patient John, albeit asymmetrical. That is the anxiety in both of engaging closely, as well as  venturing out too far. When I talk of asymmetry, it’s not that I wasn’t terribly anxious about  infecting or being infected, but that John was due to his early emotional trauma,  predisposed towards the activation of a primitive regression. I will describe how he was  plagued by terrifying anxieties, mediated through projective identification, of his primitive  destructive urges towards me. I hope to demonstrate the strong parallel that exists between  the parasitic nature of the virus, and my patient John’s frightening parasitic impulses, based  on his intense and primitive needs to enter and fuse with me. 

I will describe latter how my patient, struggled with core intimacy difficulties that resonated closely with these anxieties, which manifested for him, in the dis-regulation of the too- far (agoraphobic), too- near (claustrophobic) intimacy dialectic . As mentioned, I too 2 had to struggle with my own stress, although less intense than John’s, in managing my own  lockdown situation (akin to claustrophobia), as well as my anxiety in venturing too far from  the safety of my home (akin to agoraphobia). In this sense the pandemic could be seen to  be, in particularly vulnerable patients, both claustrophobogenic as well as agoraphobogenic. I will describe how prior to the pandemic; my patient John and I were in what might be  called, and analytic slumber. He and I were stuck in the mire of what seemed, until Covid hit us, an endless impasse. 

The role of tension and its potential for the facilitation of growth is not new. Martin Luther King Jr. in his letter written whilst in a Birmingham jail wrote:

“I must confess that I am not afraid of the word tension…….. there is a type of constructive, nonviolent tension, which is necessary for growth …….The purpose ….. is to create a situation so crisis packed that it will inevitably open the door to negotiation.

Schumpeter (1942), an economist, described the notion of “creative destruction,” as a  situation where, the “gale of destruction” is followed by the creation of the new. I will  describe how the “gale” of the destructive Corona pandemic, helped to “destroy” the collusive impasse that was co-created by my patient and I. I will attempt to show in more  detail later, how the unconstructive analysis, prior to Covid came to be, and how this Corona  force, helped to activate a third analytic reflective space (Ogden 2004).  

I will drawing on Winnicott, be describing how the anxiety generated out of the shared  external threat, although challenging, had a positive activating effect on both myself and my  patient. In particular, how the increased tensions arising out of the too -near  (claustrophobic), too- far (agoraphobic) dialectic, when contained, created a potentially  transformational transitional space which helped to enhance my patient’s mentalising and  symbolising capacity, that is, a capacity to make more from less. 

The virtue of irresolvable dialectical tensions

 The idea that creative transformational moments can be born out of tensions relating to  frustration, absence and unknowing, is central to many of our early thinkers. Bion (1962)  notes that it is the absent breast, that gives the child his first opportunity to know reality  through thought. Winnicott (1971) understood well the value of what he termed, “desultory formless functioning” , and how he believed, that it is only in this unintegrated state that  creativity can emerge. (Winnicott, 1971, p. 64) 

It is important though not to lose sight of the emphasis that these authors also placed on  the presence of the object as well. They emphasise that in order to think about an object/ breast that is absent, there has to be a well-functioning presence of a holding Winnicott (1971), and containing object (Bion 1962).  

I am going to be elaborating on the specific and potentially creative tensions that are  generated out of the irreconcilable opposites involved in dialectical processes. These  dialectical entities, although may not be obvious, are endemic to our analytical processes.  Ogden notes that Winnicott drew on a multitude of dialectical phenomena such as me–not  me, subject–object and illusion–reality (Ogden 1992). Other early thinkers, although not  explicitly, could also in my mind, be thinking in dialectical terms, Klein in her good-bad  object, present-absent breast (1946). Bion, in his container-contained (1962).   The dialectical tensions derived from apparently irreconcilable contradicting  emotional states, are well described by Ogden. 

A dialectic is a process in which each of the two opposing concepts creates, informs,  preserves and negates one another, each stands in a dynamic ever-changing relationship  with the other. The dialectical process moves toward integration, but integration is never  complete (1992 p. 208).  

It is this lack of integration and the irreconciled nature of the dialectic that is the power  generator of tension.  

My mind turns to some co- dependent couples that I see, who can’t be with one another yet  can’t leave each other, are dependent on one other and are defined by one another. These  irreconcilable tensions as can be imagined, activate enormous emotional storms in these  relationships. Life -death and closeness - separateness could be seen as such couples! 

I have found Winnicott most helpful in trying to understand the relationship between the  irresolvable tensions inherent in dialectical situations, and his understanding of transitional  phenomena, and their potential for creativity and growth (Israelstam 2007, 2009, 2016,  2018,). The infant from birth is thrust into a developmental dialectical dilemma, i.e., needing  to be with the mother, as well as without the mother; the need to hold on to the fantasy  that it possesses the breast, yet to learn to accept reality. Winnicott recognised that the  impact of the infant’s fraught transition, needed buffering. For this he introduced the  concept of transitional phenomena, notably the transitional space and transitional object  (Winnicott 1953). He saw these transitions as arising out of the me - not me, or mother- not  mother dialectic. He understood that the management of these tensions needed the  presence of a good -enough mother/therapist, who could function as a third, that is able to  hold the baby through these dialectical tensions and frustrations generated by these  irresolvable dilemmas. If this is successful, the baby can begin to move from the black and  white situation of being either omnipotently merged with the mother or frighteningly  isolated. All being well the developing child will start to feel the comfort and pleasure of  being either close or separate, as the situation requires. The developing baby’s frustration  and struggle with its irresolvable situation, together with the mother’s capacity for holding  and containment, sets the stage for its capacity to symbolise, to distinguish illusion from  reality and to begin to understand, how one thing can stand for another (Segal 1978). For  Winnicott the transitional space is a place of play, symbol formation and creativity. It is  through the capacity to symbolise that the child can learn to face reality (Winnicott 1971).  

Dialectics of life, death and intimacy

Hoffman (1994,1997,1998), drawing on his theory of ‘dialectical-constructivism’, describes  how he sees the dialectic of life–death existing as a core organizing principle, a  psychobiological bedrock. He declares that human beings can only create their sense of  meaning in the teeth of the constant threat of non-being (1998, p. 16). I will now focus on those dialectical tensions that are pertinent to my patient John and my  analytic situation, that is, to the life-death situation of the pandemic that confronted us.  

Death as the core organising principal, can be said to spawn other related dialectics that are  meta to it (Israelstam 2007). I will attempt to explain how the closeness - separate dialectic  is such one. Intimacy is traditionally understood to be equated with closeness and warmth, but if one looks at this dialectically, as a double description, a true intimate state could  rather be described as a capacity to be able to tolerate sustained closeness, as well as  sustained separateness. To be able to be with, and be without. (Israelstam1989,2007,2018).  The capacity to remain in a positive state of intimacy though, requires the presence of a  containing/holding/ mentalising third, initially externally and then ultimately internally  (Bion 1962; Ogden 2004; Winnicott 1971). Without these positive and secure introjects, (as  with my patient John to be described), being too close and or being too separate, can  activate terrifying life and death fantasies. I will suggest that being stuck in fusion or in  isolation, represents death, and where the capacity to be close, and to be separate in  harmonious oscillation, represents life. In Winnicottian terms then, it is the intermediatory  space that exists between the irreconcilable dialectical entities of life-death and closeness separateness, that when contained by a third presence, has the potential to become a  creative transitional analytic space (Israelstam 2007, 2009,2016,2018). 

I will turn now to Rey (1994), Melzer (1992) and Glaser (1986), for a deeper understanding  of the primitive mechanisms involved in the claustra-agoraphobic dynamic, that are very  pertinent to my patient. 

Rey (1994), formulated what he has called a ‘claustra-agoraphobic dilemma’. He like Klein,  evoked the dynamic of projective identification, where the patient projects primitive and  frightening aggressive destructive elements, into the object (to control and possess). This  leads to fears of retaliation, panic and claustrophobia. He then describes how the patient in  his attempt to free himself, takes flight, only to experience the terror and isolating dread of  agoraphobia. He described a situation where vulnerable patients are unable to find comfort,  either with or without the presence of the object. 

Meltzer (1992), in describing the dynamics of claustrophobic - agoraphobic situation, speaks  of how what he terms the “claustrum dweller,” who through projective identification,  projects unwanted frightening destructive aspects of self into a suffocating claustrum. He  described how he believed that the resulting terrifying phantasies, were experienced by  vulnerable patients, bodily and concretely. They lacked the capacity to symbolize or  represent these experiences internally. 

Glaser (1986) describes the concept of the “core complex”. He describes a terrifying  situation where the emotionally deprived infant is driven by powerful wish-fulfilment urges  to merge with the mother. Once inside the mother, he fears that mother will either imprison  him for eternity, or violently expel him. In fear and dread of these consequences, the infant  then takes flight, only to experience the dread of isolation. Again, this compels him to return  to the wished-for merger. A vicious cycle ensues. The infant enraged by their projected  experience of the cruel mother’s rejecting behaviour, develops sadistic destructive  phantasies towards her.  

John’s narrative 

 John in his early 40’s, is a senior IT specialist, currently in a 2-year relationship. He expressed  concerns about his difficulties in committing to his current partner, as well as his  longstanding feelings of loneliness and emptiness.  

John’s father “disappeared” just prior to his birth. He described himself as unwanted and  unloved by his mother. His mother often reminded Jack, in a blaming way, about the severe  depressive illness that she developed after his birth. He reported that he never recalls his  mother smiling. “Yet she would go on and on about how unsmiling I was as a baby and child!  I tried so hard to please her, I did well at school, hoping that this would bring her some  joy.” His mother fostered children to earn money. He described how at the age of 6, he  became aware that a little blonde girl, a little younger than him, kept on staying. His mother  then later informed him that she had adopted the girl! He described how this little girl, who  was outgoing and affectionate, brought smiles and joy to his unhappy mother, in a way that  he could never do. He felt devastated and alone, and would spend hours in his room,  involved with computer technology. 

John described himself as being fairly isolated, but for a few friends, who shared his in  interest in IT, both at school and university. He told me that he had a few relationships over  the years, but that the these often ended in a similar way, in that he was unable to commit.  He said that he had been with his current partner now for over 2 years and that he felt  attached to her in a way that he has never felt before. John spoke of how much she had  come to mean to him, and that he was worried that he would spoil this relationship as he  had done others. He said that he noticed that when she started to talk about children and  commitment, that he could see himself withdrawing, but when she threatened to leave, he  would get panicky and start to beg her not to. He told me that his partner was losing  patients with him, and that It was her, who suggested that he try psychoanalysis”. 

I came soon to understand, that John had been severely emotionally traumatised, suffering  from maternal neglect and rejection, as well as the effects of being abandoned by his father.  It will become evident in my clinical description that John’s conflicts resonated with those  described above by Rey, Meltzer and Glaser. His greatest wishes have also been his greatest  fears. In this paper I talk of this as his too-near, too-far anxieties (Israelstam1989a, 1989b, 3 2018). 

In our time prior to the Covid crisis, John appeared indifferent to our coming together and  separating, this surprised me, given his early deprivations. I would have expected stronger  reactions. I will later attempt to describe the dynamics that led to this rather unproductive  analytic state of affairs.  

I will be focusing in particular, on how each variation in the frame i.e., moving from couch to  6 feet, to screen, activated tensions that seemed to awaken both John and I, out of what I  can, in retrospect, only think of as a co-created analytic slumber. I will attempt to show that  it was only after the explosion of the Covid crisis, and the inevitable disruption of the  analytic frame and situation, that John’s core intimacy anxieties became manifest.  

Clinical Material 

Pre-Covid. 

I saw John for about a year, 4 times per week before the outbreak of the pandemic. He was always smartly dressed, well-coordinated in unchanging beige tones and was always exactly on time. He started on the chair, saying that the idea of the couch made him feel uneasy, but was unable at that stage to explore this further. 

It was not long before he began to complain, that I never smiled, and that I seemed  unresponsive, and had a very “flat face.” He began to wonder if I was really interested in  seeing him, and that he believed that I was finding him boring. I was struggling to connect to  him. He spoke slowly in low monotones, was unsmiling, rather expressionless and  unresponsive. I realised that this was not all projection, and that there was some truth in his observation. I  did feel rather flat and unresponsive much of the time.

After about 3 months, John agreed to lie on the couch. He said at least that way he would  not have to be looking at my “flat face!” When I remarked that I thought that he was  projecting the unsmiling rejecting mother onto me, he reacted saying “You are not my  mother!” I had become aware that this sort of response was not so much resistance, but  rather an indication of his rigid and non -symbolic thinking. His understanding of his dreams  at this stage, were also very concrete, and he had difficulty in associating freely. I became  aware of the parallel situation where I too had lost my usual capacity for reverie and free  flowing thought. 

This move to the couch was the first time that John revealed some reaction to change in the  distance. He began then to become concerned that I could now doze off, or feel free to think  of other things! He would frequently turn around to check, to catch me out. It did not take  long for him though, to revert to his rather nonchalant attitude. At this stage I began to feel  rather despondent about our lack of connectedness.  

When I reflected later on my contribution to this unproductive state, I realised that a  particular situation of mutual influence, had occurred (Cooper 1997; Slavin and  Kriegman1998). It was not only John’s defences that were operating, but mine as well. I had,  through unprocessed projective identifications, in keeping with Sandler’s role  responsiveness, become “influenced” by John, to become avoidant and withdrawn myself  (Sandler 1976). I in turn, not managing my projective counter- identification (Grinberg 1997),  re-projected into him, the avoidant unresponsive mother. I realise now that I had  participated in a chronic, unreflective enactment of he being again with his cold rejecting  mother. It was only after some time, that I came to understand that John’s withdrawal was a  defence against the fear of his longing for closeness, and his dread of isolation. His fear and  dread of being stuck at either pole of the dialectic of close-separate, or claustrophobia -  agoraphobia, left him “floating” in a liminal emptiness, a deadly lonely place. With healthy  intimacy the liminal space that lies between closeness and separateness is comfortably  traversed when either is called for and desired. John though who cannot comfortably  tolerate either too much closeness or too much separateness, is left stranded in an eternal nowhere land. 

The time of Covid - from couch to 6 feet

When the storm of the pandemic hit us. I was, needless to say, deeply anxious as the reality  of the virus, unseen and lethal, began to dawn on me. I was in the riskier age group, and had  anxieties not only about the viability of my practice, but whether I would succumb to the  virus! I was concerned also, as to whether I would in my survival mode, be able to offer Jack  and other patients the containment that they needed?  

John at this initial stage however, seemed relatively unperturbed while retreating into  his intellectualising and quietly omnipotent defences. He stated proudly how his scientific  knowhow put him at a strong advantage over those less knowledgeable. He proceeded in a  rather patronising way, over the next days to teach “the less knowledgeable” me, about the  rudiments of this little-known disease. He emphasised how his age placed him in a safe  position, and how people in my age group have weaker immune systems, and should be  more careful. In all this time, there was very little acknowledgement of his need for me. This  omnipotent response could clearly be seen as his defence against his growing awareness of  his dependence and need for me. 

With only one day’s notice I informed John of our need to distance. He stared at me rather  defiantly, blurting out. “The further away I get from you the better. I feel suffocated by your  smell anyway!” My first association was to smelly toilets at the train station which then led  to my thoughts on Melzer’s notion of the “claustrum dweller.” John, I realised had started to  become very attached to my couch in a rather adhesive way, as a concrete representation of  myself. When he was asked to move/distance from the couch to the chair 6 feet away, he  became very agitated, as if cruelly ripped off /abandoned. I began to have a sense then of how acutely sensitive John was to any change in our comings and goings. I thought, these  were early signs of his agoraphobic-claustrophobic dilemma.  

When he entered my room the next day, given the need for 6 feet distance, I was not there to let him in as I usually do. He looked rather bewildered and lost as he sat in the chair. His  short burst of glory over his ascendance over me however, came to a crashing halt, with our  move to 6 feet apart. His rather omnipotent defences breaking down, precipitated in him, a  huge and primitive regression. 

He sat up, red in the face. “I knew that you would be waiting for this opportunity, that you  were getting bored with me, that you’ve had enough of me!” Becoming tearful he continued. “Perhaps you are worried that I will infect you, maybe I should leave and save you the trouble!” For most of the session he remained rather silent, head down, occasionally I thought, looking longingly and hatefully at the couch/me that had abandoned him. 

At the end of the session, he left without looking at me, banging the door behind him. Clearly his past traumas of being unwanted and rejected had come alive.  John’s sudden and uncharacteristic outburst and tears, left me stunned. In the past year he  had hardly raised his voice, let alone cry. John had come alive in a lived experience of me as  the rejecting cruel object. I continued to be anxiously concerned about my own anxiety levels, as to whether I would be able to provide the containment that he would be needing.  

The following day I was anxiously waiting for John to come, wondering about his reaction.  When John entered my rooms, he looked dishevelled, so unlike his usual neat and  coordinated self. 

“I had such a terrible night; I was so anxious. I had to stop myself from texting you. I had  been watching a news report on the Corona virus. It all felt too close to home. It’s also  becoming apparent that people at my age are getting ill, and some are dying. I’m surprised  at how vulnerable I’ve been feeling”.  

After sitting in silence with head down, for a while, he quietly muttered “I’m ashamed to  admit this, but I began to panic at the thought of losing you to this virus. I sanitised my hands carefully before I came up here. I don’t want to be the one that gives it  to you. I suddenly feel relieved that we have this distance”. 

I realised that John’s isolation and fusion anxieties, had come alive in our relationship. John,  I believe was clearly beginning to develop persecuting and destructive anxieties relating to a  growing awareness of his dependency longings for me.  

I too was having difficulty in managing my own growing anxieties. I was alarmed to find that  the images of the parasitic virus invading lung tissue came back into my mind. I wondered  later, if I was being “infected” via projective identification, by John’s undigested anxiety. I sat  for some time, while I struggled, without too much success, to find my mentalising self. In  my rather uncontained state, I attempted some interpretations, relating to his feared wishes,  which only served to render John more persecuted. At this point, I focused rather on trying  to strengthen my capacity to be able to be emotionally present with him.  I continued to see John at a distance in my rooms for about another 10 sessions.  

6 feet to flat screen 

 We had just in the previous few weeks begun to make some adjustment to the new frame,  when the government declared a lockdown. I eventually succumbed to the pressure from  my concerned close ones, to go virtual. I was very worried about not being able to do  effective therapy using virtual media for therapy, as I had little experience of doing this.   I was dreading so much John’s response to this change, recognising now how sensitive John  is to shifts in our frame. In my anxious avoidant state, I put off informing him of this until his  last session of the week on Friday!  

John became very angry and persecuted. “You just spring this suddenly on me. You could  have given me more notice! Why can’t we continue this way? We have distance  and sanitiser. You would know that in lockdown it is still permissible to leave home to see  your psychiatrist or psychologist. So, this is clearly your choice!” 

He carried on like this for about another 10 minutes, then suddenly went silent, becoming  very tearful.  

“I was getting used to the distance, even your unsmiling face, at least I could see you. I fear  that with the screen I’ll lose you! I’m worried that I’ve become too dependent on you. I  would like to be able to tell you to go to hell, but I can see that I’m going to have to comply!  Why did you leave it until Friday to have to tell me, how do you think I’m going to manage  over the weekend, it’s all about protecting yourself isn’t it!” 

 I felt deep shame at my avoidant behaviour in leaving it to the end of the week to inform  him of the changes. This time I realised that I had yet again participated in an enactment. It  has occurred to me, that although enactments are usually co-created ( Jacobs 1986), this  one could be thought of as a ‘triadic enactment’, in that it involved John’s coercive projective  identifications, my identification with these, plus the added effect of the external corona  virus. This enactment opened up in John, his lived awareness of both his need for me, as  well as his fear of losing me. Yet again, I had to work hard at recovering my third reflective  position. I knew that for his increased tensions to become constructive, I would need to be  able to function as his containing and mentalising third. (Ogden 2004). 

 I remarked, “I can see that I have pushed things too far for you. It was insensitive of me not  to give you more notice of the change in our setup. This thoughtlessness on my part must  might I believe reenforce your feelings that you don’t have needs, and that it’s only mine  that matter. It might be an idea then, if we meet in my rooms one more time, before we  move to online. We will need to spend some time working out the best way to do this”.  He sat silently for a few minutes, “Yes I do think another day will help.  

It was our last session before moving onto Zoom. As I waited for John’s arrival, I was aware  of my anxiety, both in regards to what reaction I should expect from him, as well as my own  anxiety as indicated regarding the radical change in our frame. 

John looking tired and dejected. “I had such a terribly disturbing dream last night. I was in a  tented refugee camp. I could hear bombs exploding around us. I was cold, hungry and  terrified, waiting in a long line to receive food rations. A man in a red cross uniform was  handing out the food parcels. By the time I got to the end of the line, I was told that it’s too  late, that he has gone home. I know that this is about you and me. I couldn’t fall asleep after  that, feeling so angry and let down by you being so uncaring and insensitive. After a while  the churning that I was feeling settled, and I began to think about our session on Friday. How  you apologised and spoke of how we could work on the best way to make this change. I felt  a little more included, and warmer towards you and fell asleep. I’m not used to  people apologising. At home it was always my fault!”  

Yes, I agree that the dream is about you and me. You who’s about to become a casted out  refugee, and me the unavailable Red Cross man.”  

John replied: “Yes I do feel lost and confused about you”. 

We spent most of the rest of the session discussing the various options available for us to  connect virtually. He immediately discounted the telephone. “I could never find you that  way! I prefer to try with the screen, I need to be able to see you.” 

The Flat screen

It was with great trepidation that I anticipated this change to screen. John and I, had only  just began to adjust to the first assault on our frame. I could hear though the echoes of  O’Shaughnessy words (1964 p.34). 

“This fact, that the internal situation declines in the absence of the external object, poses a  difficulty for development. The internal object must be kept alive, or else at each re-union so  severe a setback has occurred as to make a continuous relationship impossible”. 

The day we started, it felt to me like we were like a couple on an awkward first date! John  had to call me, to let me know that the Zoom password that I had sent him didn’t work. It was only a few seconds into our session, when John exclaimed, “This is not going to work.  I’m worried about your lack of IT skills; you couldn’t even set this up properly! I’m not  feeling safe with all this”.  

I suggested that he was letting me know that he had lost some of the trust that he had been  developing with me. That he had become concerned that I might not have the skill to  manage him under these new circumstances.  

He responded with a sarcastic bite. “There you go with your fancy analytic words again!  How can I trust you, if you are hardly here, just a 2D cut out, you are more interested in  being a clever psychoanalyst than in me!” At the end of our session, he did the equivalent of  banging the door without a goodbye, with a flick of the exit mode! 

 I realised that with this move to screen, I had, together with the demands of the pandemic,  precipitated another enactment. When John spoke of my lack of IT skills, I suspect that he  had picked up in me my anxiety and doubt about my capacity to cope with this new virtual  setup. This was not all his projection.  

The next day we connected on time. John was very agitated, shifting about in his chair.   “This is not going to work I’m telling you! I hardly slept, I had terrible nightmares. I was  surfing huge waves, like the ones that I usually do. I was suddenly thrown off my board. I  saw the fin of a large shark, I shouted to the lifesaver. He was so engrossed in reading his  book, that he didn’t notice me. I felt myself drowning, struggling for air, then woke up  sweating”.  

When I asked him for his associations he exclaimed, "Please this is not a time for  psychoanalysis, there’s a fucking virus out there that could kill both of us, and when I most  need you, you are not with me, I’m seeing that flat dead face again”.  

While sitting in the long silence, thinking of John’s experience of me with the “flat face”, my  mind drifted to Tronick’s still face experiments (1989,2007), I could hear Tronick saying in the  same vein as O’Shaughnessy (1964), that the repeated experience of the mothers returning  engaging face is important for the child’s development. The problem arises when the  mother’s reappearance is absent or erratic. The real shift away from the bodily proximity of  my consulting room, plus the concreteness of Jacks experience of me as 2D, left him  struggling with my still flat face. I felt some despair, wondering if Jack would be able to find  me, under the new conditions of this Covid restricted frame. I was also concerned again,  whether I would have the containing capacity to be able to “save” him in his unbalanced  precarious state, leaving him as in his dream, to be thrown to the sharks. 

For the first few weeks, it was again, as if John never stopped complaining about my  deadness and my lack of interest and concern for him.  

We continued with the remote analysis for the next 12 weeks. As the weeks unfolded, Jack  spoke little. When expressing his concern at not being able to feel enough of my presence, I  noticed though, that with time, he was becoming more sad than angry. He was also less  rejecting of my attempts to link his feelings to his early experience of deprivation.  At one point he told me how he had considered recording our sessions, so that he could  have me in- between sessions, but decided not to. When I enquired about what stopped  him, I noticed him beginning to wipe his tears away as he spoke. “I felt so ashamed.  Recording the sessions would have highlighted how much I needed you.”

In one of our sessions, John asked if I could have more light in my room, saying that I was  too backlit, and on another occasion, he asked if I could move closer to the screen, and not  sit so back in my chair. I took this as a desperate and concrete plea to try and find me, and  not a means of control. On this basis I moved more forward and added the light from my  desk lamp. John seemed relieved, and in a quiet voice said, “That is better”.  In a tearful voice, just before the end of the session, John uttered “ I so miss being in the  same room with you”. 

I reflected to him how confused and unsettling it must be for him, missing me when I’m too far away, but when we were in the room, he complained about being too-close.  “Yes, it is confusing,” he remarked quietly.  

We were getting closer to the end of our three months of on- screen therapy. John was  beginning to talk more openly of how he missed me between sessions and over the  weekends. He would be very tearful when he began to recall how neglected and lonely, he  had felt as a young child. He spoke often of how he would cry himself to sleep, and how he  was determined not to be heard, as he knew that he would probably be reprimanded. “I  tried so hard to please, not to be any trouble”. 

His anxiety about my health also became more apparent, the slightest cough or clearing my  throat would make him anxious. There were growing signs of him being able to begin to  have concern for me.  

Return to 6 feet in room

Almost a year had passed since the Covid pandemic began, when the Corona situation was such, that I began to feel safe enough to see my patients in my room, at the required distance. John was on the one hand clearly relieved at being able to be together with me, but not unexpectantly, my bodily presence continued to activate his too-far, too-near anxieties. He spoke about how the virtual set-up, on the one hand gave him some safe distance from me, but how this also frustrated his wish to be closer to me. John was clearly more open now, in being able to reflect on his experience of my comings and goings. He slowly began to feel safe enough to speak of his anxieties, as well as his hostilities towards me, both when he started to feel more attached and dependent, and also when we parted after sessions. He began to share more dreams, that spoke of both his claustrophobic and agoraphobic anxieties e.g., one where he was being engulfed in a tsunami, and the other  where he was lost alone in an endless desert.  

Although John still has a long way to go, there was evidence of a distinct shift in his  development.  

John has become committed to his work and continues to see me regularly. We only  recently, because of a sudden lockdown, have moved to screen again. This precipitated a  small regression that settled down in a few days. He is clearly becoming more able to feel  connected to me in a virtual situation. This I believe is a sign that he was beginning to show  early signs of a capacity to mentalise and symbolise. 

Discussion

As described above, when confronted with the existential realty of death, John and I shared  the same anxieties of being too-close or too-far. On further reflection, I have come to realise  how difficult it was for me to function as a firm containing third and mentalising figure for  John, given the effect that the deep death anxieties brought about by the invasive Corona,  had on me. John’s experience of me at times, of my not being there for him, was not simply  based on projection, but of his recognition of my own insecurity and anxiety.  

It could be seen that the situation that John and I were in, had been one of mutual  influence, or not to overplay the metaphor, one of mutual ‘infection’ (Cooper 1997). The  threat of suffocation and isolation generated in us both, albeit asymmetrically, primitive and  destructive anxieties such as described earlier by Rey (1994), and Meltzer (1992). These  primitive phantasies as these authors described, were mediated through the process of  projective identification. John, filled with sadistic and aggressive impulses towards me  would, as Rey and Meltzer described, project these onto and into me, only to be persecuted  by his destructive impulses and fear of my retaliation. In order to manage my own anxieties,  it is conceivable then that I like John, evacuated that that was unprocessed in me, back into  John. It is this recursive vicious cycle that I see more in retrospect, that has made my work  with John, that much more challenging of my containing capacities.  

Rey (1994), has referred to patients, similar to John, who lack symbolic capacity and think  concretely. He points out that because of their concrete thinking, the damage that they have done to their objects, is experienced as real and actual, rendering their anxieties more  intense. All the more important then, has it been for me to be able to facilitate this process,  to work at being able to provide the containing mentalising third that was not available to  John himself. 

Given the importance that I have given to the function of containment of the dialectical  anxieties generated in the context of our struggling frame, I believe it is worthwhile  describing the notion of containment in dialectical terms. In this mode then the reflective  third is represented by what might be termed a dialectically attuned therapist (Israelstam  2007). The dialectically attuned therapist functions by mentally/emotionally processing the  anxieties that are continually being generated by the colliding differences activated by  opposing, yet interdependent dialectical elements. The dialectically attuned therapist,  regulates the oscillation according to the system’s demands, by attending to each dynamic  figure-ground oscillation in relation to each unique moment in its relational configuration. In practical terms, John when too-close panics, seeking air moves to a too-far position, then  panics seeking connection etc. My containing/holding John while in panicked close mode, as  well as when he is in panicked separated mode, allows him gradually to begin to confront  and reflect on his subjective fears, hopefully to the point where he feels safer when close  and safer when separate. 

When there is however a breakdown or absence of a dialectically aware ‘third’, fluid  dialectical oscillation is lost. It is under these conditions that there is then a risk of rapid  dialectical ossification and what I have termed dialectical atelectasis . (Israelstam 2007).

Conclusion: Making more from less

It is an irony, that it took the anxiety generated by the “gale” of the destructive force of the suffocating and isolating pandemic crisis, to breathe life into our pre-covid slumbering analysis. It took as Luther King wrote, a “crisis-packed situation” to bring about a resuscitation, resulting in the potential development of a third reflective space! I have emphasised also how my own anxieties, together with John’s, contributed to the mutual and escalating “infecting” of the other, and how this rendered my task of containment and dialectical attunement, so challenging. I described the part played by the  intrusive pandemic, in the activation of a number of enactments that evolved in our analytic  work. As noted earlier, I have suggested that we could talk of these, as being not only co created, but tri-created, the third element being the pandemic itself. 

As the time progressed, although often with the utmost difficulty, I was more and more able  to process my own anxiety and fears as described above. This enabled me to offer John the  containment and dialectical attunement that he required in being able to manage the  increased tensions arising out of the too -near too- far dialectic. This resulted in the creation  of a potentially transformational transitional space, a third presence, which helped to  enhance John’s mentalising and symbolising capacity. This growing capacity, reduced the  potency of his concrete persecuting and sadistic phantasies as described earlier (Rey 1994).  As a result of this, John was gradually able to find some comfort when connected to me, and  less anxiety and hostility when we were apart. He was able to spend less time alone lost in a  liminal wilderness, as he had done prior to his analysis. It is this growing capacity to  symbolise, that has enabled John to make more from less. 

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