Interpreting and holding, and the unconscious roots behind the conscious sense of dread in a time of national crisis.

Introduction

This discussion offers some initial clinical impressions in response to the COVID-19 pandemic. This paper by no means represents a final word on this subject, and as I explore the phenomena of this crisis and its effect on psychoanalytic psychotherapy, I see countless important areas that need addressing in the time ahead. But as in all discussions, we need a starting point.

At the Vanguard

Psychoanalysis has long stood at the vanguard of every world calamity, inclusive of war, famine, natural disaster, political oppression, and of course, as in today’s circumstance, a serious health crisis in the form of life-threatening pandemic. Unlike other health professions, psychoanalytically oriented therapists are not typically in the public forum and outwardly engaged in social causes (of course there are many exceptions). Generally, the psychoanalytic psychotherapist works in the private confines of their consulting room intensely engaged in deep therapeutic conversation with a single patient (although marital, group and family work can also part of it). The psychoanalytic therapist influences society from a location of one person at a time, one interaction at time, incrementally over time, which is barely registered in the macro picture especially in times of a national crisis. Despite this, each day and each week, and each year, the psychoanalytic psychotherapists, often despite their own circumstance, stand at the forefront of facing and holding each of their patient’s individual conscious and unconscious conflict that are often accompanied by a sense of fear and dread.

Therapeutic Action

Psychoanalysis is not a science created from lofty academia but built on the intensive continuous clinical engagement in an effort to find relief for human mental suffering. In the wake of this viral epidemic the psychoanalytic psychotherapist is especially challenged to address the ongoing crisis through their clinical understanding and acumen. Jeff Seinfeld (1993) identified

Page 1

the two key clinical actions of psychoanalysis as “interpreting and holding,” which come very much to play in these days of dealing with this pandemic, as we will see in the clinical examples.

Recently I have encountered a number patients begin the session with a catastrophic comment, “looks like we are all going to die,” “this is the end of the world,” “I feel a complete loss of control,” “I live in terror,” or, “I don’t know what is going to happen to me, or my family,” “I have this terrible feeling I will not only be sick but broke too.” All these comments and their various iterations speak to one feeling, that I will call “a sense of dread.”

It would be rather insensitive and dismissive on my part to jump into psychoanalytic unconscious motivations regarding this “sense of dread” and not acknowledge the serious life and death reality of this pandemic, and the short-sighted mismanagement and denial from our government that has put us months behind in testing, funding, treatment and containment options, only amplifying the sense of anxiety that runs as rampant as the virus itself. The psychoanalytic psychotherapists live in the same world as their patients and are subject to the same environmental threats and health concerns. We also must acknowledge that psychotherapists also feel their own sense of anxiety and even dread is such a crisis. Yet as psychoanalytic psychotherapists, we have chosen a path of creating intimate close connections with people over time in the confines of our enclosed consulting rooms. This pandemic sets up an incredible challenge to this paradigm rupturing the regular flow of contact and connection. In a future paper, I will discuss new emerging paradigms for treatment, but for now we must address the emotional state of “dread” that lies at the heart of our work that defines these difficult times.

Merriam-Webster tells us that “dread” – as extreme uneasiness in the face of a disagreeable prospect, or from The Cambridge Dictionary simply put,“a strong feeling of fear or worry.” We don’t need be psychoanalysts to recognize how a potentially catastrophic viral outbreak would create such severe worry both threatening our lives and our livelihood. There is no psychoanalytic writer/theorist or for that matter clinician who has not confronted the issues surrounding feelings of overriding dread in the face of societal catastrophe. It could be postulated “dread” is the fundamental affective experience that belies nearly all symptoms and reasons for entering therapy in the first place. A severely depressed “blue collar” male patient who secretly struggled with his sexual identity unconsciously manufactured a severe respiratory condition.

Page 2

With advent of fearing death, he felt compelled own up to his truth which he dreaded sharing out of fear of extreme rejection and shame. He broke down in one session and “came out,” and much to his surprise his world did not end, and within a month of that session his breathing issues and sense of dread dissipated like a cloud, and his new life began.

This very brief example was only used to demonstrate that a sense of dread is something that comes in the form of thoughts past memories mixing with current feelings and circumstance. The patient’s guilt and shame, and fear of persecution and abandonment were antiques of a troubled childhood that continued to cast a shadow in the form of symptoms and dread that dominated current life.

In psychoanalytic circles, it is a common belief that external circumstance merely provides a medium for the therapeutic exchange, and generally external circumstances are used by the patient as both a facilitator of deeper conversation and a resistance to the deeper conversation, and sometimes both. In psychoanalytic terms we are often thinking about what lies beneath the current emotional situation and distress. This of course has implications for our current state of environmental threat.

A very successful woman nearing seventy recently expressed deep duress and “overwhelm” regarding the pandemic not only for her health and the health of her children but for her finances. “I am so worried, I worked my whole life, and I now will lose everything, I have no control, I feel helpless (she begins to cry). I sat quiet allowing the emotional truth to emerge without distraction. After she regrouped, I pointed out this was not the first time she has experienced a loss of control (I worked with her for quite some time). She seemed confused, “What do you mean?” I pointed out many instances that she found herself in what seemed to be a severe crisis (or felt that way) and that we successfully worked through it. She seemed relieved to be reminded that she was resilient. I then wondered that this loss of control that she emphasized regarding the pandemic somehow mirrored her early life circumstance related to the terroristic unpredictable violent attacks by her abusive mother. [interpreting] The patient then experienced a linking moment between her current sense of dread from the virus and her early pre-verbal and middle childhood circumstance. Then after making the connection between the two, she said, “I want to breathe now, this whole situation takes my breath away.” I reframed her comment slightly suggesting, perhaps your breath was not actually taken away but rather you are

Page 3

holding your breath because you live in a world that can be unpredictable and dangerous, like with our current pandemic.  Holding one’s breath is a natural occurrence in a state of fear, I said. She liked the reframing thinking it was less passive to hold one’s breath then to have your breath taken from her. [interpreting] She then remarked by the close of the session, that she felt a sense of relief knowing that she endured many critical circumstances which made her grow, and that she actually is quite resilient. She thanked me for reminding her of this. [holding]

The existential threat from this virus even though it is a collective societal event is always in the final analysis experienced through the personal lens of one’s own existence. The “dread” that is common to us is an understandably ubiquitous affective response to such a situation, especially in this early phase.  Yet, the dread we speak of does not arise from this pandemic alone but also a product of and a connection to the archaic resonance of a time when we were absolutely dependent on the other for our survival. Simply put our life is in hands of a sometimes “not good enough” other. This theme of environmental failure of provision and protection runs through most of Ronald Fairburn’s work, as well as the writings of pediatrician turned psychoanalyst D. W. Winnicott, the two strongest voices of the British school of object relations.

These theorists /clinicians saw the infant as precariously in a situation ruled by rather unpredictable and at times unreliable caretakers, who for a variety of reasons become “not good enough” even destructive, when the infant is in a position of having no defense against such failure. For Winnicott, who was no stranger to cultural calamity as he witnessed the Blitzkrieg at his doorstep, labeled this early state of precariousness as “annihilation anxiety,” because essentially without the necessary provision, the infant would feel a kind of panicked non-existence, or in other words, a “sense of dread.” Winnicott (1986) wrote:

Anxiety in these early stages of the parent-infant relationship relates to the threat of annihilation… Therefore, main function of the holding environment is the reduction to a minimum the impingements to which the infant must react with resultant annihilation of personal being. (pp. 243-44)

It is a quick jump to interpret that if our society/government/work routine/therapy relationship representing the “holding environment” then with the advent of this environmental calamity, representing a significant rupture or impingement to “continuity of being”(as Winnicott would say) we would indeed experience an emotional event in the form of a “sense of dread”, which sets in motion the search for an object to provide comfort. The therapeutic relationship first and

Page 4

foremost is a supportive experience, whereby the individual under threat seeks shelter and a safe port to feel less alone, in other words, the holding action.

The dread is not only what is remembered but also the fear of what could be lost. For another woman patient, who lived through profoundly abandoning parents and an unfaithful husband, found herself depressed stuck in a service-based reality living in a world never having her own voice. After much therapeutic work she has freed herself from servitude as has begun to experience the world with a renewed sense of confidence and purpose. Yet despite this, the pandemic cut her off from her newly found routine and lifestyle and thrust her back to the home of “menial domestic chores” which brought back her depression. Usually upbeat and optimistic she experienced an uncharacteristic sense of despair and dread that that she heretofore had put aside years ago. In an off-handed comment, she mentioned that did not hear form either parent during this stressful time. I suggested that her despair may be a form of grief or abandonment feeling [interpretation], inasmuch that even though her parents are alive they have not checked in with her to see how she was doing. The patient immediately remembered that she recently had an impulse to visit her hometown which was “weird for me” since she has spent her life distancing herself from that place. She was upset as she spoke, thinking that her time in that town was the last time she had both her parents under the same roof with her. The pandemic seemed to rupture her current new routine thrusting her back to her days of despair and aloneness, remembering her father leaving and her mother’s aggressive outbursts and how “trapped” she felt.  It was the word “trapped” that linked her to her experience of having to stay home and return to domesticity, which meant returning her to the time she had no voice:

I don’t want to remember the past so much but keeping busy and doing my own thing these last few years I had a taste of a different life, this experience brought me right back to those horrible days, even though I know this is temporary.

The pandemic can also represent not only link to earlier memories of dread, but as in the above the fear of losing what has been finally gained. I mentioned someone starting the session with the comment that “we are all going to die.” His provocative rather morose comments were typical for him, often preoccupied with death; the truth was that he was very worried about losing what he has attained. In a way his comment was a sort of an evacuation of the “worst case” scenario to vent his fear and vulnerability, which he admitted later in session, especially the prospect of possibly losing his mother. More than six years ago the same fellow was arrested for aggravated

Page 5

assault and was addicted to opioids, indeed his world had ended. But his world really ended before that: at age nine he was the victim of sexual abuse that he long ago repressed and retrieved later in his analysis. He got out of the criminal charges and then went into recovery through NA, and has been sober since, and now is on the verge of getting a promotion at a serious job, has his own apartment, reconciled with his immediate family, became engaged, has set a date to be married, and looking forward to fatherhood. Linking to his arduous journey to live a functional life, the last thing he wanted was for all of us to die. The patient acknowledged his sense of guilt and the cruel punishment he deserved for his countless misdeeds when he was an addict.  I interpreted that perhaps he spoke the worst cases a way he could protect himself form the deeper pain and guilt of actually losing what he was worked so hard to attain. [interpretation] He then began to feel the pain well up inside him as the session ended.

Many Rivers to Cross

The pandemic has heightened our consciousness to the everyday gifts of the minuscule elements of our life and journey that we often take for granted. The pandemic reminds us, in an affective sense, of a pre-verbal time when we were at the complete mercy of at times cruel, negligent, unpredictable and even destructive environment. The story we are describing is ubiquitous as Fairburn suggests, a universal happenstance that when at our most vulnerable we are bound to be hurt, overly frustrated and discombobulated, and at worst tortured and abused. That is what this pandemic represents a return to that place of complete vulnerability having to rely on the caretaking others of our government, medical establishment, and industry to “do their job” and protect us from harm and disruption.

We needn’t look to far in the past to see Freud’s valiant work as he faced anti-Semitism (and its most virulent version in the Nazi era), poverty, a world war and cancer, while maintaining a thriving practice and originating a whole new science of the mind. We also must remember that Freud experienced the full brunt of the 1918 Spanish Flu epidemic that ravaged Europe with the tragic death of his beloved, then pregnant, daughter Sophie Halberstadt-Freud in 1920, due to complications from the illness. Freud wrote to Pastor Pfister on January 27, two days after Sophie’s passing:

This afternoon we received the news that our sweet Sophie in Hamburg had been snatched away from us by influenza pneumonia, snatch away in the midst of glowing health, from a full and active life as a competent mother and loving wife, all in four of

Page 6

five days, as though she never existed… Although we had been worried about her for a couple of days, we had nevertheless been hopeful; it is so difficult to judge from a distance. And this distance must remain distance, we were not able to travel at once, as we intended after the first alarming news; there was not train, not even for an emergency. The undisguised brutality of our time weighs heavily upon us. Tomorrow she is to be cremated; our poor Sunday Child! … I work as much as I can and I am thankful for the diversion. The loss of a child seems to be a serious, narcissistic injury; what is known as mourning will probably follow only later.

We quickly recognize that Freud’s letter could have been written last week, not 100 years ago. I italicized the section that spoke of the “distance must remain distance”, which rings so true today as Freud confronted the same travel restrictions and reality we are facing in our own communities, and by extension throughout the world.  In reading this letter we see how that history often repeats, in fact Freud taught us this. This pandemic has brought to us front and center an existential threat that comes with a “sense of dread” that often ignites the most primitive existential anxiety that is part and parcel of our own early childhood experience. The very fact that people participate in psychanalytic psychotherapy tells us they have already experienced one if not many existential threats at an earlier time that comes into our offices in the form of symptoms, dreams and conflicts. Even those who are not in therapy, they too feel the dread of this pandemic and the anxiety of having to change one’s life in unexpected and sometimes radical ways which can also conjure long repressed anxiety and fear. Psychoanalytic psychotherapists are poised at the forefront of this calamity, not only ready to engage and provide a sense of holding to our patients through this crisis, but to use this moment to create a greater depth understanding of our individual and collective experience of being human. As psychotherapists we recognize in this time of national crisis it would be common for our own sense of vulnerability would be merged with our patient’s vulnerability and could induce strong countertransference anxiety. Thus, it is especially important for the psychotherapist to be mindful of their own internal feelings when working on the front lines guarding against the ever-present contagion of dread. When Winnicott spoke of “annihilation anxiety” as a fundamental truth of all humans, he also recognized simultaneously that unique ability in humans in their capacity to exert resilience and persistence in the face of all challenges and crisis. In other words, despite the many rivers we must cross, humanity has a way of creatively engaging this ever-changing landscape to make, unlike Aldous Huxley’s dystopian vision, a truly brave new world.

Page 7