THE COVID MONTHS | You can Keep your shoes on
Having passed out stone cold on the clinic floor when eye drops were administered, it was generally agreed that the only way to get me through simultaneous bilateral cataract surgery was a general anaesthetic.
After two weeks of quarantine and a negative Covid test, I finally lay on the hospital trolley in one of those embarrassing medical gowns that only have ties at the back. The nurse looking after me struggled to undo my knots. I was not about to give up my modesty without a fight. Having finally succeeded, she asked me to confirm my full name and date of birth to prove that I was the right patient. In the circumstances, I did not think that this could have been in doubt, but procedure is procedure. As I don’t own any slippers I had walked to the operating theatre in my shoes. They were still on my feet peeping out at the end of the trolley. A medical oversight?
‘What shall I do with my shoes?
‘You can keep them on.’
That couldn't be right! I had just had to isolate for two weeks and then do the test before I had been allowed into the hospital. I’d worn a face mask, sanitised at every gel station and kept my distance. My brain went into turbo charged calibration and came back with three words-‘ That is wrong!’ I had to put this delicately, I didn’t want to provoke any irritation in someone who literally had my life in their hands.
‘Oh! I can keep my shoes?’
‘Coward!’ shouted my inner voice.
‘Ok, ok back off. I’ll give it another go.’ I promised.
I tried again, ‘ That’s ok ... is it? Keeping my shoes on?’
The inner cacophony this feeble second attempt aroused was drowned out by a drug induced loss of consciousness. Blackness descended.
The next light I saw was through closed, sticky eyes that just wouldn’t open. The warm, reassuring voice of Philomena Cunk[1] was asking me how I felt. Did I have any pain. I realised I did and she said she would give me something to help. A few minutes later it hadn’t helped and so she gave me a top up. Then a bit of a row started with a disembodied man’s voice over to my right demanding to know if I was supposed to have morphine. But my protector saw him off with a few sharp staccato sentences from my notes. I lost track of a wispy, uncurling question that was trying to form in my head about the ethics of arguing over the top of the patient about their treatment. Then the pain stopped. Philomena told me I was doing really well which was nice to know. When I got back to the ward someone told me they were going to take my shoes off before helping me into bed. I couldn’t have cared less what they did.
Philomena Cunk
Paradigm shifts are everywhere around us. From face masks to lockdowns everything has morphed into a different iteration of itself. Doing things differently is the new constant in a social landscape that has been ravaged by our love of being close to each other. Now physical closeness is one of the biggest taboos of our time, forbidden in law and punishable by hefty fines.
As psychotherapists we have in a few short months done the impossible, abandoning our consulting rooms, those confidential sequestered spaces where no intrusion is allowed to encroach, for digital spaces in spare rooms, hastily constructed corners of dining rooms and even tents. Family members have been banned from entry with fierce signs on doors warning them to keep out. Some are even vanquished from being in the same building when we talk to our clients. Pets have proven problematic. Cat tails have crossed our screens at unexpected and inopportune moments. Dogs have crashed through reflective silences with frenzied canine barking and the odd personal item has made it into view – an item of underwear on a radiator, the face of the window cleaner, or a scarily titled text book, ‘Normality & Pathology in Childhood’, ‘The Narcissistic And Borderline Disorder’. We have all taken crash courses in working online and schooled ourselves in the etiquette of working digitally - Beware of disinhibition, don’t finish off your morning toast just as you fire up the camera. Don’t consume hot drinks whilst you work. If you need a sip of water make sure you don’t lift the glass so high that your face is hidden by the bottom of it. Dress in a Zoom-appropriate style at least on your top half. Blue shirts are good for the guys and scarves or higher necklines work best for the gals. Then there are the questions. If my lower half remains hidden is it ok to wear slippers, loose lounging pants or shorts? Or does this detract from my inner readiness to assume the healing mantle? Do I unwittingly act in a less professional way if I don’t dress fully in role?
As a profession, historically, our biggest changes have invariably been provoked by external circumstances. Perhaps one of the most notable in the last 45 plus years has been the Vietnam war. PTSD became universally acknowledged as a syndrome due to the high numbers of veterans suffering serious mental health issues. A new psychiatric diagnosis, post traumatic stress disorder (PTSD) was introduced. The traumatic costs of war were finally no longer attributed to cowardice, shell shock or a weak character.
Covid-19 has opened up the reality of working remotely in ways that previously would have been unthinkable. Client and therapist no longer need to be in the same place, the same continent or even the same time zone. This is more true for work with adults than it is with children and young people. Some therapists rejoice in working from home for a whole range of reasons – it is easier to fit domestic chores in around sessions, there are savings on travel time and travel costs, and sessions can be arranged in a more fluid way including from holiday locations. Others chafe against the lack of separation between work and home. Negative transference is less easy to separate from if you are stepping out of your spare room straight into family life without a location fire break. Bumping into colleagues, sharing a coffee, catching up with each other in the relaxed, flowing way that comes with sharing a work space are all lost. Catching up from the self isolation of a home work space becomes more formal, it has to be intentionally planned, spontaneity is less free flowing.
Sitting with our clients has been different in these months. We are in two separate rooms not a single shared one. In non-Covid times the therapist defines, protects and manages the external boundary. A hugely significant and important transaction of both practical importance and symbolic meaning through which the therapist uses their presence to sculpt and craft the sacred shared space in which the client will make their journey of personal discovery. The client can give up responsibility for anything external and so be more free to enter their inner world unencumbered and free of practical concern for privacy. We all know the importance of entering the right space. Finally sitting in your seat on the plane taking you to the holiday you have battled so hard to reach. Sitting in an outdoor jacuzzi with the warm water enveloping you and the night sky above. And, yes, even lying in the ante room of the operating theatre knowing that others will take over now and your inner dialogue will be silenced. Entering the sequestered space stops the voices that battle against us giving in to letting go. We can finally plunge into the hidden depths of our private inner world. It is nothing short of phenomenological alchemy. For the client this is an ‘unthought known’ .[2] The familiar repetition of a ritual that gives the therapy its ambient temperature, its rhythmic familiarity and anchors it in a space and place that belongs to another time warp.
We lose some of our most valuable channels of communication when we no longer meet together in the same physical space. We are trained to understand and read non verbal communication valuing it as beyond price in our efforts to walk with our client inside their world. When we are no longer in the same room together with those with whom we sit so much is lost. To work wisely and well we need to account fearlessly for what has been lost with the opening of the digitalised Pandora’s box. The therapeutic relationship needs to be given a voice, like a victim in a court room, to speak its truth and share its impact statement and we must listen and plan accordingly.
We have lost the depth and richness of many if not all forms of non verbal talking. Eye contact, facial expression, gesture, posture are all diminished if not extinguished. Obscured and reduced to a bit part, non verbal communication is in danger of becoming a caricature of itself. Body language is limited to the upper body and even then becomes camera enslaved. Under the watchful digital presence time inclines to the monochronic. We look to actively account to the camera for our interest and involvement. Self-conscious demonstration of our interest and connectedness pushes and jostles its way past quiet, reflective presence that is unspoken but deeply felt. Time is more deliberately managed and arranged. Relational psychotherapy and counselling are inherently polychronic. The client and therapist are connected by the unfolding phenomenological rhythm emanating from the client’s inner world. Words are not always necessary or even desirable. Shared silence has its own deep, rhythmic power transcending time and place. Time may hang heavily, it may stand still it may pass in a flash according to the terrain the client is travelling. It has an inherent rhythmic liveliness that is often lost in the digital world. Martin Buber writes,
“The (therapist) must feel the other side, the patient’s side of the relationship, as a bodily touch to know how the (client) feels it.” Merger without merging.
The meaning of space is entirely lost when we cannot sit in the same room together. Proximity and distance are made redundant and cannot take their part in the rhythmic therapeutic dance. People are pinned by the camera and the microphone to an infinitely more static form of expression stripped of shade and tone.
Our client’s body is obscured, embodied dialogue is much harder to see and hear. A tapping foot, a gurgling stomach, the scent of hungry breath are lost to us. Walking into the room and out at the end are in the unilateral control of the therapist. The client has so much less agency.
In 1909 E.M. Forster wrote The Machine Stops a futuristic tale of people living isolated and alone connected to each other by The Machine. In this extract Kuno tries to explain to his mother, Vashti, why he wants to see her in person.
‘She touched the isolation knob, so that no one else could speak to her. Very well. Let us talk, I will isolate myself. I do not expect anything important will happen for the next five minutes – for I can give you fully five minutes, Kuno. Then I must deliver my lecture on ‘Music during the Australian period’. … But it was fully fifteen seconds before the round plate she held in her hands began to glow. A faint blue light shot across it, darkening to purple, and presently she could see the image of her son, who lived on the other side of the earth, and he could see her. …’ I have called you before, mother, but you are always busy or isolated. I have something particular to say.’
‘what is it dearest boy? Be quick. Why could you not send it by pneumatic post?’ ‘Because I prefer saying such a thing. I want –‘ ‘Well?’ ‘I want you to come and see me.’ Vashti watched his face in the blue plate. ‘But I can see you!’ she exclaimed. ‘What more do you want?’ I I want to see you not through the Machine,’ said Kuno. ‘I want to speak to you not through the wearisome Machine.’[3]
The ’wearisome machine’ will be with us for some months yet but it is no substitute for being together in the same room.
[1] Philomena Cunk is a comedic persona of actress Diane Morgan.
[2] Bollas, Christopher, (2018). The Shadow of the Object. Psychoanalysis of the Unthought Known. London: Routledge.
[3] Forster, E.M. (1909) The Machine Stops. Oxford & Cambridge Review.