key: cord-0709853-1h7iuqey
authors: Trotta, Barbara; Mosconi, Andrea
title: The Paradoxical Effects of COVID‐19 in Italian Systemic Practice: Clinical and Teaching ‘Insights’
date: 2021-03-15
journal: Aust N Z J Fam Ther
DOI: 10.1002/anzf.1441
sha: 4143cc6e726c515ee6b623865f6e23392bea452b
doc_id: 709853
cord_uid: 1h7iuqey

The COVID‐19 pandemic has impacted the personal and professional lives of all of us and has laid the bases for a social and cultural change. This article is written as a reflection on the paradoxical effects of the ‘viral phenomenon.’ We wish to highlight the opportunities and changes that have arisen from the emergency situation, especially through the use of the online setting, both in the clinical work and training activities of systemic therapists. This article is not intended to be a panegyric on the merits of digital sessions, but an appraisal, also through clinical examples, of the contributions that technology may give to our practices. We do not consider technology as a substitute, but as an integration and enrichment of the therapist's and trainer's tools. This tough experience may be transformed into an opportunity for learning new techniques and practices in which the screen becomes a useful support.

The experience of the pandemic continues to impact our personal and professional lives and more generally the social, economic, and environmental macrosystem. There was a respite in the summer of 2020 during which the pandemic was contained, but we are now in the second wave. Earlier, one of the authors, elsewhere, as a sort of systemic mantra had asked himself: 'Perfection, what does this allow me to learn?' (Amorin-Woods et al., 2020, p. 9; Mosconi, 2020) . Along this path, in the same paper, Amorin-Woods et al. (2020) suggest seeing the pandemic as an opportunity for social change.

We are aware that in this moment the virulence of COVID-19 produces an economic crisis and a global emergency: a contagion with exponential spread, intensive care and emergency departments are once again at their limits, people find themselves out of work. Despite all of this, we think it is necessary to reflect on how we can benefit from this viral phenomenon.

A Meta-reflection on the COVID-19 Pandemic This article is written within a frame of complexity inspired by the irreverent stance (Cecchin, Ray, & Lane, 1992) to which one of our masters of the Milan Model, Gianfranco Cecchin, refers. We highlight the opportunities and changes that are taking place in psychotherapy, both in clinical practice and training, in the critical situation of the pandemic. What we ask ourselves, in the spirit of second-order cybernetics, is, which maps can we use for the new scenarios that are taking shape from this emergency? This means making room for flexibility, a curious attitude, and the research of unusual solutions, when we find ourselves in front of the critical issues dictated by the conditions of the virus. As Tettamanzi (2020) underlines in the June issue of Connessioni, the magazine of the Milanese Centre for Family Therapy, dedicated to COVID-19: 'we cannot avoid . . . it is inevitable, a degree of meta-reflection on the process in progress and on the psychological and social impact of what is happening.'

At a meta level, the coronavirus is changing the conception of time: the measurable entity, Chronos, leaves space for what in Greek etymology is called Kairos, the 'right and opportune moment.' Kairos implies a vision of time that deals with the need for the effectiveness of human action and transcends a measurable duration: everyone knows what the most suitable moment is. For example, since the pandemic, smart working is restructuring how we conceive and plan work; it is no longer dictated by conventional office hours, but rather focuses on the quality of results. This not only implies more adequate and appropriate time management, but also the overcoming of physical and territorial boundaries in various contexts.

We therefore can also conceive of therapy and teaching through the advent of digitisation, specifically with the introduction of the screen in therapeutic and training settings. 'Online therapeutic work, although it is far from proposing itself as the only and incontrovertible reality, appears however, more and more, as an opportunity. Therapy cannot escape coming to terms with the digital anthropological mutation that has been going on for the last twenty years' (Vallario, 2020, p. 94) .

What Can We Learn for Clinical Practice? Online therapy was, before last spring's lockdown, the domain of just a few; others used it occasionally and/or as an experiment. It has now become the only tool for many therapists to continue treatment processes. Giuliani (2020b) , in a review of Luca Vallario's text, 'Lo schermo che cura. Psicoterapia online tra clinica e formazione' (translation: 'The screen that heals. Online clinical therapy and training') quotes the author as saying that it is no longer a small group of digital natives wondering how to integrate new media into clinical practice. The topic becomes increasingly more relevant for those who care about the possibility that this profession responds to ever new questions. This means that the use of technological support in therapy is not simply confined to those who are computer literate, as it had already entered the therapeutic setting about 30 years ago (Borsca & Pomini, 2020, p. 37). Vallario (2020) defines first-generation tools like the advent of the telephone and, second-generation tools, those that imply asynchronous communication (SMS and mail). The virus has done nothing more than show the opportunities of the third generation's synchronous communication. The use of video-calling platforms is a unique change in the history of psychotherapy due to the shortness of time in which it has occurred. It has upset the setting's rules and habits and the ways in which sessions are conducted (Albertini, Manfrida, & Eisenberg, 2020) .

In this regard, we want to list the opportunities that we have noticed in our clinical practice during these months of intensive use of online therapy under the following headings. While we are aware of issues that are not favoured by the digital setting, we leave them aside in this paper.

Face-to-face contact, during 'traditional' sessions is, in this moment, obscured by the mask and by a greater distance in space. This, in certain situations, can be an obstacle to the therapeutic relationship. On the contrary, in the online mode, although it is not possible to see the totality of the client's corporeity, the face is well exposed, and all its expressiveness can be grasped. The enhancement of facial mimicry, where each micro-variation of the face can be mutually grasped by the therapist and the client, can be useful because it can allow greater awareness of one's own expressions in relationships; this is true for both the therapist and the client. A more conscious use by the therapist of the vocal non-verbal (tone and volume of voice, duration of speech and pauses) and of the kinetic non-verbal (especially the oscillations of the waist that can be pushed forward or backward according to the amount of emotional closeness that the therapist thinks is helpful to communicate to the client). What is important from our point of view is that the therapist is aware that they can use these non-verbal aspects. For example, when an emotional abreaction occurs, it can be contained precisely through a warm tone of voice, slowed speech, and closer eye contact.

Faces in the foreground have the effect, in our opinion, of a greater focus of attention, which can favour, in some cases, a faster mentalisation. Our use of this term follows Fonagy, Gergely, Jurist, & Targe's (2004) definition, and refers to the ability to make and use mental representations of our own and other people's emotional states. So, if some authors have seen faces in the foreground as facilitating the symmetrical relationship between client and therapist, we see the opportunity for a reflective activity particularly favoured by constant eye contact. The opportunity, through technology, to enter clients' homes, as a sort of virtual home visit. This can have several advantages: on the one hand, it facilitates access to psychotherapeutic paths even for people who would hardly ever access them, for example, individuals who have been isolated at home for years. On the other hand, it allows access to resources and/or permits observation of aspects of therapy that would not be available in the session and/or would be observed differently. Nisse (in Amorin-Woods et al., 2020, pp. 12À13) says that in online sessions, 'the surprise are mutual, arrive directly in their living room, or their office,' and 'sometimes a decorative detail jumps out at me, so "connected" with the patient's problem that I cannot avoid referring to it'. As an example we will describe a brief case study. The client is a 20-year-old male with performance anxiety in evaluation situations, especially during university exams. While we were working online and co-constructing with him the personal resources that he could activate in these situations, a poster of a TV series behind him came in handy. In the poster the protagonist is a strong guy, who fights, who is never afraid, and who frequently uses reassuring phrases. It is positioned behind the client in such a way that the character appears on the monitor right next to him. Therefore, not only can the client imagine that the character can speak to him with words of encouragement, but he can also see the strong guy right next to him, which enhances the effectiveness of the stimulus. This illustrates how working with the person directly in their environment, through a digitally mediated setting, allows the therapist to find solutions that are tailored-made and meaningful for the client. 'Technological tools enhance creative abilities' (Francescato, 2020, p. 14) . The use of platforms like Zoom that allow a virtual whiteboard to be shared can be an opportunity to co-construct therapeutic resources. For example, a 17-yearold girl always adhered to family expectations, achieving excellent results in school and sports activities but as a result saw herself as passive and unable to make autonomous decisions. She either adhered uncritically to what her parents proposed or considered drastic solutions in clear opposition to her family with no possibility of finding a middle way. One of her interests was playing the piano, to which she dedicated herself daily. In therapy we used musical language, through the analogy of 'variation on the theme,' to introduce an idea of flexibility. A variation is any re-proposition of a musical idea whereby changes, which can be more or less profound compared to their original form, can occur. It can concern various aspects: harmony, melody, counterpoint articulation, rhythm, instrumental timbre, dynamics, and even formal organisation. Specifically, with the aim of facilitating mentalisation, this analogy was used as a keyword supported by symbols shared on the virtual whiteboard, which offered an opportunity for the co-construction of meaning using a visual modality. Seeing on the screen one's own image while seeing the client allows the therapist to constantly be self-aware, in the therapeutic relationship, of their own corporeality: the experience of being able to see their own activity while carrying it out can only enhance the reflective function (Giuliani & Mendini, 2020) .

Ensure continuity of therapies, for example, when clients need to transfer permanently or temporarily to other geographic locations for work, health, or family needs. In these situations, consider a digital example. A 27-year-old girl, after graduating and working for several years, decides to leave her job to start studies that can give her more exciting job opportunities. In this phase of reorganising her life, she has for one year commenced an important emotional relationship. She is planning to move in with her partner and often moves from one city to another to meet him. The online mode has allowed a stability in the therapeutic work that would otherwise have been fragmented if the client was in her home town only at certain times. 'The deterritorialisation': digital technology allows the flexibility to manage urgent traumatic situations in red areas, that is, in those areas that are isolated to reduce virus infection. Let us think about grief, violence, separation, and all those situations that require early intervention to prevent post-traumatic disorders. In these circumstances, delaying treatment to work in the therapy room would perhaps mean having to postpone to months later, as happened during the spring lockdown. This seems to us to be a cumbersome solution both on an ethical and a deontological level. Take the example of a 40-year-old man who, a couple of weeks before the lockdown last March, suffered the death of his partner. He started therapy because he had post-traumatic symptoms: insomnia, general agitation, intrusive scenes of his partner's death, which had in fact occurred before his eyes due to a sudden heart attack. Remote work, in those months in which the National Council of the Order of Psychologists had advised its members to move therapeutic work online, made it possible to stabilise the client. What could otherwise have resulted in a post-traumatic disorder, if we had waited months to return to the office for treatment, was stemmed. In this sense, online therapy at this time had a secondary preventive function regarding the onset of traumatic complications (Giuliani & Mendini, 2020) . Moreover, the 'deterritorialisation' of the therapeutic relationship favoured by digital instruments allows those who work at the forefront of the pandemic, primarily doctors and nurses, to be able to access psychological support which they would otherwise probably not have time for because of pressing shifts. The same goes for those who live in 'red zone' areas without services and who cannot access psychological support. We also add the possibility that has arisen from the spread of distance therapy of being able to choose the best therapist for the person, thus using not only territorial proximity as a criterion. Other colleagues have already emphasised the benefits of the diffusion of distance therapy, for example, for emigrant clients. Giuliani (2020a, p. 163) , in this regard, says that when people move to other countries 'if they are looking for a therapist, they look for an Italian speaking person' for various reasons. 'On the one hand, the language with which the person has learned to name his/her emotions is the one with which it is easier to talk about oneself' (p. 163). Albertini (2020b, p. 114) , referring to Italian emigrants, says: 'perhaps, a certain mental setting of sharing cultural absolutes is more important, for our clients, than sharing a room. We work with words, and we cannot fail to understand how important it can be for a client to feel completely free to speak his mother tongue. A second language, even if perfectly spoken, will never have all the nuances and contours of the language that we carry in our inner world since childhood.'

By 'diagnostic' we mean making visible aspects of therapy that would remain on a predominantly narrative level in a 'traditional' setting. We specifically refer to some clients, such as people with borderline personality disorder, although we do believe that face-to-face treatment is more suitable with them, and that online work should be limited in time. We noticed that the dissociating effect of the screen allows us to observe parts of the self of these clients that usually remain less tangible in face-to-face sessions; for example, a physical restlessness (moving in space, smoking, eating, etc.) and the externalisation of anger, also towards the therapist. These aspects, once acted out, become clinical material on which to work once we return to the therapy room. Albertini (2020a, p. 188) says about these clients that 'online communication, which by its nature solicits a certain process of disinhibition and increases aggressiveness, can be symptomatic in these situations.' A clinical example is the case of a 45-year-old woman who, before the March 2020 lockdown, was treated in the therapy room by one of the authors. In that setting, she behaved in a submissive manner. However, she described herself as being seen by others as 'a lioness.' When she contacted the therapist between sessions via WhatsApp, she was polite and respectful: 'Excuse me, doctor, could you call me back if by any chance you have some time available?' Some weeks after the closure due to the increase in infections and the transition to remote therapy, the client during an online session manifested an unexpressed anger towards the therapist. In the following session, when talking about this, the client explained that she didn't want to have therapy that day. This externalisation, favoured by the fact that the screen sometimes disinhibits, made it possible to highlight a part of the client that had remained only on a narrative level when they met in the therapy room. Starting from this acting out, it was possible to begin a deeper and more restructuring work with her, which we summarise in the following intervention: 'when she cannot express her needs, she reacts by roaring like a lion.' The possible use of digital tools not only for individual therapy, but also for couple and family therapy highlights how, in the online mode, boundaries and alliances between the system components are very often immediately identifiable. We can observe how the family decides to connect: whether together from a single location or separately. In the latter case, different configurations may appear. For example, parents from one location and children from another, the mother with a child on one side and the father with another child on another side, all family members from different connection points while sharing the same living space. This aspect, which instantly manifests in remote therapy, can be a gateway to highlight how the system's subjects perceive their relationships. This mode, as far as we are concerned, is a novelty to working under the pandemic. Previously the use of the webcam took place only with a family member who was abroad for study and/or work and the rest of the family was present in the therapist's rooms.

Video calls have frequently been the exclusive vehicle of contact in contexts that are not necessarily clinical, such as communities, rest homes, and hospitals. It is therefore possible to prevent and/or mitigate social detachment and the consequent mental distress. To these points we want to add two more reflections that are not strictly connected to remote interventions, but have immediate repercussions from the environment of the pandemic.

It is a reality that clients and therapists share the common experience of uncertainty dictated by the spread of the virus. The opening conversations of the sessions, very often, are precisely those concerning updates on the pandemic. This, from our point of view, puts therapists and clients in a situation of 'equality.' It can be useful for the therapeutic alliance because it creates an emotional climate of closeness. We have also noticed how some types of clients, such as those who lived in social isolation before COVID-19, or those with obsessive rituals regarding cleaning, felt 'normalised' on a social level. This had a beneficial effect on their mental health.

What Can We Learn for Training? We want to point out the following opportunities for remote psychotherapy training connected with the characteristics of the online setting and the resources available.

The simultaneous presence of teachers and students within a shared screen, where each icon is next to the other, without distinctions and/or hierarchies, can facilitate a 'closeness' between the interlocutors, regardless of the role. This implicitly seems to favour a co-constructed teaching. The fact that the icons on the screen move makes each trainee change their location in the virtual space in each lesson and within the same day, also based on who enters and leaves the connection. This removes the fixity of places, and therefore of relationships, which is likely to occur in face-to-face training. This difference recalls an idea of equidistance and the development of, perhaps less intense, but more widespread relationships that favour a sense of belonging to the group. An increase in order and mutual respect: the 'flattened' presence of the monitor, and therefore the absence of corporeity, leads each student to intervene, paying attention to others. So, to avoid overlapping, they very often book their turn to chat. The support of e-learning platforms where it is possible to upload materials, slides, exercises, articles, becomes a great resource; an archive always available for students. 'Through the web, students can gain access to a plethora of didactic materials and become more autonomos. Digital technology offers support and new instruments for a wide range of CFT training activities, from a simple task, such as constructing genograms to more complex ones, like rating of psychotherapy sessions for training or research purposes' (Borsca & Pomini, 2018, p. 631).

An increase in the focus of attention as elicited for psychotherapy. Vallario (2020) writes on this topic that 'the direct relationship with the screen increases the focus of the student's attention' with an impact also on self-reflection. The usefulness for students to be able to watch their recorded therapy sessions from home. This allows them to focus on the various segments and notice the significant therapeutic interventions, which is important for learning how to conduct therapy sessions. The opportunity to create subgroups automatically, with some platforms. This may promote greater opportunities for students to meet without a controlling action on the part of trainers. As already mentioned for clinical work, the sharing of the virtual whiteboard or of the chat favours mentalisation thanks to the use of keywords through the support of the visual channel. A more precise structuring of the stimuli and exercises proposed by trainers. This is because one cannot rely also on the co-construction facilitated by faceto-face conversation. 

The pandemic has initiated a digital driving force that is expanding our possibilities as systemic therapists and trainers. Technology has now entered therapy rooms and is an additional device that we can use to expand our toolbox. Everyone will be able to use it in the way that they find most congenial without running into the uncritical risk of being a technophile, but at the same time not wishing to appear a traditionalist.

The use of the screen, in particular, for therapeutic processes becomes a clinical reflection: in what situations, and with whom, is it most useful? Online therapy, according to Martorelli (2020, p. 33), 'can be useful, even indispensable, in certain situations, in certain contexts, under certain conditions, first of all when dealing with temporariness.'

It is therefore reasonable to become aware that psychotherapy is changing and equipping itself with new languages and new instruments. The COVID emergency, precisely because of its unpredictability, requires greater flexibility in interventions and the online setting is an evidence of this phenomena.

We see implications for systemic therapists that involve both practical work and research. The online modality is applicable for both therapy and training in systemic psychotherapy. The use of digital platforms makes it possible to take advantage of new languages and tools that are consistent with the epistemological premises of the relational approach. Distance therapy can be applied not only to individual paths, but also to couples and family therapy.

Future research may focus on the following topics:

What can favour the online therapeutic relationship? Which techniques can support the online mode? From a wider perspective, in which situations can distance therapy be useful? For which clients is it not advantageous and recommended? Verify the effectiveness of therapeutic paths mediated by the screen compared to therapies with classical settings.

There is already some research that has studied these phenomena and it is providing positive feedback in support of webcam interventions. The authors therefore hope that this procedure can be integrated into their practice, in situations that require it, even after the pandemic. This is also a way to keep up with the times: digitalisation has taken hold in our daily lives and is changing our way of thinking.

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The Paradoxical Effects Of COVID-19 In Italian Systemic Practice ª 2021 Australian Association of Family Therapy