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Undoubtedly we are all facing a new situation, unthinkable for each of us, only similar to the stories of war lived and told by our grandparents and great-grandparents and that we felt so distant. From a therapist's point of view, it seemed to us that they had penetrated the personalities of the subjects in a profound way, leaving marks in several generations (including our own).

 

From the path of Mental Health, we are called to respond in these times of crisis, because, regardless of the approach, object of study, or whether we do psychotherapy or pharmacotherapy, what moves us is the welfare of our patients and eventually of society.

From Grupo TFP Chile - a group of professionals dedicated to working with Personality Disorders from Transference Focused Psychotherapy (TFP) - we also feel part of this call and believe that it will be a great challenge to address how the world has been forced to dismantle aspects of its great collective self. We see the grandiosity of nations and people breaking down before our eyes and making way for the suffering and pain of uncertainty and fear that it generates. In the same way, we see how the reactions are different: some look for guilt, others resort to idealizations that allow them to overcome these affections of anguish, uncertainty and pain.

 

Being present in different ways.

 

From this prism, the thrapeutic work at this time is crucial: our patients are going through an endless number of proceses that have been precipitated on them by the external situation, and have come to remove their internal worlds. Although, a great number of therapist, we do not have a Hippocratic oath, we do know that at this time the work of supporting and cointaining our patients is crucial.

It is in collective crises that we are called upon most not to abandon the relationship with the patient. We know that in the bond lies much of the expected change in the patient, so today more than ever we must be available. We hope that in this period each one of us can continue with our work, even more so when studies already indicate that the Chinese population has experience 5% of acut symptoms of post-traumatic stress due to the epidemic, and that the consultations to our speciality are going in frank growth.

However, we usually deploy our work of a relational nature, in that particular scenario wich is our private office or other places were we do our therapeutic labor, so we are facin the great challenge of being able to move this framework to the terrain of the virtual, the only safe contact space possible in this state of emergency.

In this context, how can we continue to care for our patients? How can we continue to care in a safe environment for both and also for the therapeutic process?

 

Practical recommendations

For both therapists and patients, this is an unknown terrain, which in many cases generates mistrust. However, we invite you to explore it by following some basic recommendations. Many will be surprised at how ¨easy ¨ can be followed.

 

In order to transfer our field of action to the online world, we need to know the local law. In the case of Chilean, the law 20584 regulates ¨Rights and the duties of people linked to their health care system¨. In particular, in paragraph 9, ¨the rights of persons with mental or intellectual disabilities¨ do not refer to the online form of care; however, we suggest trying to be as much as possible in this new modality to what is dictated by this law.

• Make sure you have an adequate internet connection. If you can connect via cable and not via wifi; this will give you stability to the connection and avoid the sensation of frozen image.

• Use a video call service that is secure. There are some that comply with HIPPA data encryption standards. In addition, if the chosen method records the communication, your patient must be aware of this and authorize it.

• Make sure your patient does not record sessions without your knowledge.

• Test your communication system with a colleague before your first visit.

• Orient your camera so that your torso is visible to the patient, not just your face. Ask the patient to do the same, as this will make it easier to capture non-verbal language in both.

• Before each session you and your patient should minimize computer or smartphone applications and notifications like whatsapp desktops, mail, etc., in order to decrease distractions.

• Ensure that both you and your patients have an uninterrupted session. Remember that interruptions in a virtual space will be both, so you should take care of the potential noise environments of your ¨virtual office¨. Don't forget that the new setting will reflect aspects of us that were previously unknown to the patient, so you should invest in choosing a safe care space. Make sure that this is constant during the time that the online care modality lasts.

• Make sure to recreate the conditions as close as possible to those of a consultation. Both should be sitting in front of the screen and the screen should be fixed, taking care when one of the two should use a smartphone. They should not be lying down, but properly dressed, not eating, etc.

• Ideal if both can use headphones, as this provides a greater climate of intimacy.

• Keep an adequate ¨distance ¨ between both. Be careful not to talk over the screen, but patient and therapist should sit at a certain distance from it, giving the feeling of being in a room.

• Discuss with your patient the fears raised by this change in framing and take the time to do so.

 

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Reorientation needed

The confinement situation may require you to consider new elements in your therapy contract. Discuss this with your patient primarily and if so, redirect the treatment to this point.

On the other hand, it is undeniable that our treatments will be colored by reality and its weight. You should feel free to address this as much as necessary with each patient, so if you find that the point of greatest affection is in the external reality, we suggest to direct the treatment to this point. Attention during this period subordinates the internal world to the conditions of external crisis, and only when the work on it has been contained, we suggest that you redirect to the usual dynamics of working with each one.

As always, the framework addresses safety and risk issues first. We invite you to review with your patients whether they adhere to safety practices with respect to the virus. In this way, pandemic care becomes a priority topic in the hierarchy of topics to be addressed in each session.

Certainly, some patients are uncomfortable with this new format and will have more difficulty adapting. However, we have seen that with others a rapid climate of intimacy is generated in which the usual transferential dynamics can be explored without difficulty. In view of the precipitation of affections in patients produced by the international situation, we hope that some processes may occur more slowly than in a classical therapy; especially accompanied with more feelings of vulnerability. It is then time to contain these and transform them into mental contents for the patient. And to do so not only through verbalization, adequate interpretation, but also through a neutral attitude and an adequate management of the regulation of emotional involvement, fundamental techniques in these moments to transmit confidence and tranquility.

Verónica Steiner Segal

Grupo TFP Chile Coordinator

TFP Uruguay Member

TFP Teacher and Supervisor, certified by ISTFP

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You can read this article in spanish or in french.

• Spanish

• Francés

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