We are all struggling right now (even therapists). Here’s how to identify challenges that you might not realize are pandemic-related.
During this pandemic, nobody is safe! We are experiencing all sorts of risky situations. One of the most challenging ones is not visible and may not be on many people’s radar: our mental health. As aware as we need to be of being able to pay our rent, it’s paying our mental duties by taking care of our emotional reactions that is just as important. Having someone who provides help in that endeavor is really calming and assuring. Those people are the psychotherapists. They’re the behind the scenes frontline mental health providers.
To honor therapists, I’m including paragraphs about therapy and therapists specifically. If that doesn’t apply to you, you can skip those paragraphs without missing the content of the article.
Being a therapist is a challenging profession. Every individual is unique and there is no one technique, modality, intervention or philosophy that could be applied to a selection of people with guaranteed results. We always have to be investigating further, learning new approaches, going out of pocket for supervision and having our own therapy in order to become more confident, more effective, more centered and more stable for ourselves and our patients.
Being in the business of helping others to grow and heal from mental illnesses is toiling! And during this time, being a therapist presents an extra set of challenges. Everybody is struggling emotionally at this point; therapists are exactly at the same level of risk than every other person. Therapists are also afraid of dying or losing something of value. I recognize it in me and I imagine many others could find it hard to take care of people while they are still puzzled about how to take care of themselves. On top of the pure difficulty of the job, and the personal toll, there is now an added layer of distress: it’s becoming clear that our minds and bodies are reacting to the pandemic in ways that we were not familiar with before.
During this pandemic, every single person has been challenged in different and mysterious ways. And there are no specialists in the matter because nobody alive has been through an experience like this — no books to consult, no modalities, no experts to be found to learn how the treatment plan should go, what to do that works best, what to avoid or what to look for in the mind or the behavior of the client during these circumstances. Shall we ask about their fears, their finances, their health? The way they are protecting themselves and others? Their responsibility to the well-being of the community? Traditionally, we don’t. Should we? What about boundaries? Shall we make them more flexible? Could they? Which ones?
I’m part of a very seasoned group of therapists running one of the most sought-after trauma programs in New York; one of the best in the country. We train clinicians to become trauma therapists and to become more confident practitioners as they work with cases that are complex for them, and debilitating for the clients. We carry the extra weight of being the “experts” at telling the people we train — and all the people that attend our workshops — how to proceed during the pandemic with their clients.
All in all, we have managed. After many meetings and many conversations, we’ve been able to use the information from the experiences with our personal clients to create solutions. Together with our supervisees and their clients, and with what we read and research, we have been able to identify several of the most important issues to focus on in order to improve our interventions during the quarantine.
The list of issues that the pandemic is causing is long and applies to everyone — therapists and people not connected to therapy as well. These identified issues incorporate the many different aspects of the crisis that are affecting our mental health and the complications in solving them. If you’re on either side of a therapy session right now, you should know that there are reasons why it’s a struggle and that you should stick to the plan of working with your mental health more than ever; the struggle is going to help your growth.
If you are not in therapy, I’m going to elaborate on some new patterns and problems that affect everyone and that might currently be getting ignored. Or maybe they seem obvious, but even if you think you have figured out how to feel better, it is no easy task keeping up with the many issues that will continue to pop up. Either way, we all should be more proactive at taking care of our mental health. We need to acknowledge all the issues that can be causing permanent psychological damage.
Recognizing the Crisis
The United Nations Development Program states that the coronavirus COVID-19 pandemic is “the defining global health crisis of our time” and the greatest challenge we have faced since World War II. Still, people want to believe it’ll be over soon, and may disregard some of the red flags. Crisis brings chaos, confusion and emotion, and when we don’t recognize and accept the crisis, we may be neglecting the internal chaos, puzzlement and the set of emotions that we experience.
I’m guilty of this. I was with my children celebrating Mother’s Day (in masks) and we remembered that the last time we met — at the end of March– we said that the next time we’d meet we’d be celebrating the end of the quarantine. We laughed and teared almost simultaneously. Denial was with us six weeks ago, and even when is less obvious now, it still lingers in our minds. We were making plans for our next gathering wishing — and secretly believing — that it will be coronavirus free. Our logic says one thing but our emotional responses don’t follow. We know this is going to stay longer than a month, but it’s too hard emotionally to accept. We rather go on in denial, or dissociate from the pain. At least for Mother’s Day!
Many of us want to continue living our lives as usual, and resist the idea of living through a real crisis for longer than “40 days.” From the Oxford English dictionary definition of crisis, we see that part of the nature of a crisis is that it’s a time “when a difficult or important decision must be made.” It can be easy to think that if we are not affected, we can check out because we have nothing else to contribute. We may need to realize that this is one of those moments where we need to forget about our individualism and become part of a collective. Part of acknowledging that this is a crisis is not so we can be scared, but so we can see that it is not happening to each person individually, that it’s happening to all of us and we need to become one in the effort to solve the future. My hope is that our future is free of mental issues or psychological trauma.
In therapy, for example, the theory says that a crisis should be dealt with in very specific ways that differ from our regular weekly sessions. The definition of crisis intervention used for therapy from the Encyclopedia of Mental Disorders describes it as “the methods used to offer immediate, short-term help to individuals who experience an event that produces emotional, mental, physical and behavioral distress or problems.” This type of intervention aims to restore equilibrium to the bio-psycho-social functioning of the person affected by the crisis to minimize the risk of developing long-term psychological trauma. We are experiencing “an event that produces emotional, mental, physical and behavioral distress or problems” but we don’t know what immediate or short-term means at this point. This crisis doesn’t have a clear turning point for action; we may not know when to shift gears towards the crisis intervention. Is it when they get the virus, or when they lose a loved one,or get laid off? Or is it today, every day, as in everyday is a crisis? Is it?
Recognizing the Challenges
The challenges I chose to include in this piece are some of the ones we don’t experience on a regular basis, especially as a collective. If we have them in mind, we can help ourselves maintain our mental health in check.
Uncertainty: not knowing activates the amygdala almost as much as danger itself. Gneezy, et. al. found that the uncertainty effect can lead people to make decisions that are irrational to the point of being absurd. People are so averse to uncertainty in general that most people are willing to pay money to avoid it, or even pay a higher price now even if the uncertainty could result in a lesser loss. Right now I’m seeing two extreme reactions to the uncertainty: People are demanding to open the economy even if that means a higher risk of getting infected and dying — and “killing” others on the way — or they are making the decision to be in complete quarantine for as long as needed, even if it’s a year or two, skipping family gatherings or going to the supermarket. They have already given up living in order to survive. Both reactions might not be best for the person and have repercussions emotionally. Elaborate a plan in your head you can believe in, and stick to it. It is more important at this moment to believe in something than to have it.
For a therapist, this could be especially challenging. The client may rely on the therapist’s point of view to make a decision and the therapist is as puzzled about the future as everyone else. Supporting the clients’ decisions could go against what the therapist is doing or believe should be done. Cognitive work (top-down) may feel fake and superficial, while somatic work (bottom-up) may be extra challenging without the mobility of the work in person. Mindfulness interventions could be the most effective right now, if they both can stay mindful during the session.
Lack of touch and human connection: “touch deprivation” can impact people at a psychological and physical level. According to Dacher Keltner, a psychology professor at the University of California, Berkeley, touch activates a big number of nerves in the body and secretes hormones that strengthen the immune system, regulate digestion and improve sleep, besides activating parts of the brain that increase empathy. This negatively affects everyone in isolation. Some self-care practices are what is required: shampoo your head for longer, put lotion your whole body, slowly, at least twice a day, wear your best and softest pajamas at night and the silkiest shirt during the day, practice pampering yourself as you have never had the time to do it. You deserve it, but you also need it. Laugh with your friends and forget about competing.
Lowering the levels of empathy carried by the loss of touch and isolation is highly problematic for therapists. Not feeling the same level of empathy as before the virus may bring feelings of inadequacy for the people that need empathy as the tool to perform their job; it could increase fear of failure, and an extra activation of stress. To recover empathy and presence, therapists could work on providing some type of healing: from sensate exercises to long warm baths. Pets are also highly effective and some people are adopting pets as we speak.
Privilege or lack of it: nothing about this virus is comprehensible. Therefore, the issue of privilege is appearing either as an entitlement or as survivor’s guilt, while the issue of racism and discrimination is showing up as a huge stressor among Asian, African-American and Latin people, which increases rejection, separatism, segregation and fear of the other. Experiencing feelings of rejection towards the other could be very detrimental to the understanding of each one’s identity and sense of self. The crisis could just get worse. This is becoming an issue that may not have adequate venues for resolution. At least we need to be mindful of it in order to avoid what is outside of our awareness. Many of the reactions we get into are part of automatic responses of survival unless we take control of our thoughts, values, convictions and actions.
For therapists, the need to address these concerns in sessions is becoming even more relevant now, and the interventions need to be timely to avoid affecting the communication and rapport between client and therapist. If a client feels that this issue is ignored, it could create a rupture in the relationship. How to bring it up depends on how solid the relationship with your client is and whether or not it has been mentioned before. For developing cultural competence in therapy I highly recommend the Laura Brown book “Cultural Competence in Trauma Therapy.”
Ambiguous loss: according to Pauline Boss, ambiguous loss is “learning to live with unresolved grief.” We as a community may be experiencing lots of losses during this pandemic; from the death of someone, to the loss of hope in the future. We don’t know where we stand, and we can’t predict what’s next. We feel a constant sorrow without knowing what to grieve. Many clients have lost jobs, money, stability. One of my clients cried half the session last week because he “never had the chance to say goodbye to his friends” when he moved from NY to CA. The friends are all alive, as is his pain. We all need space for this type of grief even if some people find it foreign.
Many clinicians have lost clients due to multiple reasons. Many people are not showing up to therapy as before, exactly in the times they may be needing it the most. This can be very destabilizing for a therapists’ emotional life. Losing a client is painful. Losing your therapist is painful. Having your therapy sessions through a screen may bring feelings of ambiguous loss because it may take time to develop the skill to attune as before. My approach is to mention it to my clients. Bringing myself into the work is effective when it is sincere and relevant.
Attachment issues: We are losing the capacity to connect and attune because we can’t look at each other eye-to-eye. This brings up issues with our attachment patterns. I’m not saying face-to-face, but at each other’s eyes; when we look at the screen, we are not seeing the eyes of the other person since the camera is catching the eyes looking somewhere else. It can’t be more disorienting for a person that needs to convey an emotion not knowing if the person on the other side is looking at his/her email. Most people with attachment issues regularly feel not seen, and the Zoom meetings can’t be better representations of that problem.
On the other hand, isolation is accentuating the attachment styles of each one: a number of people feel they are “going crazy” without others, while some are secretly enjoying not having to spend the day surrounded by colleagues. Neediness and avoidance are becoming severe traits exacerbated during this time. Feelings of abandonment are also rising, especially having so few people we could trust right now; it feels like nobody will protect us, creating a sense of orphanhood that is difficult to bear. To feel a little better even with everything against us, you can practice some visualizations: imagine an angel hugging you before falling asleep, imagine yourself in a beautiful place with your best friends, give your mind some company by connecting with loving and fulfilling moments. The brain is very appreciative of these types of thoughts. They give it hope.
Trauma therapy is highly relational. Some of the work of dealing with complex trauma is to reparent the brain of the person who experienced attachment ruptures early on. Attachment work without attunement is like running without leaving your chair. It’ll take some time to develop the skills to harmonize with the energy of the other through the screen. I think we just need to be aware of this need and start practicing. I heard some clinicians mentioning they are using a different device for sessions with no email, text or phone services to avoid the distractions. Others have mentioned asking the same from clients. The therapeutic space should be as sacred as it was when we were in person.
Many therapists have been trained to avoid mentioning their personal lives. Dogmas before COVID-19 need to be re-evaluated. Nobody knows if the changes are right or if they are failing the rules. And what about people who can’t be totally themselves because someone can be in the other room, listening to the conversation? The ego that used to be concerned about the judgment of clothes is shifting to the concern about having secrets discovered.
Privacy: teleconferences have brought us to each other’s living-rooms, bedrooms, kitchens. We can see the decoration style, the pets, the socio-economic situation of the person on the screen; kids are appearing in front of an important meeting asking for dinner. Lovers are mourning, while the brave ones are venturing to parks to clandestine encounters. Most people have completely lost their privacy and “personal space.” I wonder for how long can we sustain it and if we need to learn to set a different set of boundaries than before, to our children, to our cravings, to our needs. We could start today by realizing we have needs, and we have to ask for them to be met. Using the right language and the positive intention, you can recover some privacy. Zoom even has a digital background that blocks people from seeing your bed. You can also set up a space for your video chats and dress for the occasion. That could give you a sense of normalcy and control.
Technology and mental exhaustion: there is no published research yet, but by empirical evidence, I can assure you that trying to behave as normal when limited by the space of a screen in front of you all day is absolutely exhausting. Many people told me a month ago that it was going to be a matter of days for our brain to become used to it. It hasn’t. Every day may be more challenging than the previous one, not only because of the screen, but because we are flooded by stressors; technology adds a whole set of frustrations and miscommunication: the delay in the speech, the regular momentary freeze of the face and voice of the other, the low resolution of some screens, the password and the links, the uncomfortable comfort of our sofas and our half shown bodies. All of that just accumulates to the emotional fatigue, and to the brain’s overload. One remedy is to sleep longer and go out for walks in open spaces. The brain needs to recognize the world after hours of being in a virtual reality.
Defeat: mental defeat is a state of mentally giving up during challenging situations associated with a perceived loss of autonomy, free will and self-esteem. It has been identified as one of the most important peritraumatic predictors of PTSD development. The pandemic can easily get us into this state: we feel trapped, lacking control over our decisions or others’, helpless, disappointed and possibly hopeless. But remember that mental defeat is a mental attitude that doesn’t need to become a reality. Even when the situation is not favorable or disinvites feelings of success, we don’t have to give up our ambitions. Life is long and after this crisis, we will have lots of opportunities to conquer many of our dreams. We can start planning them now that we have some extra time. Whatever we want, except succumbing to the sense of defeat.
Recognizing the emergent traumatization
Traumatization during the pandemic is a process that carries on quietly but persistently in our system because of the risk of dying or of losing something as valuable as life — family, livelihood, health or whatever each one of us individually considers crucial. These “adaptive” actions modify the regular functioning of many of our organs, processes and brain performance with the purpose of keeping us alive. If we don’t send the signal to our brain that we are safe, the process will continue and it’ll become maladaptive. The initial adaptation is the traumatization process, while the maladaptation will turn into PTSD or psychological trauma. How do we know if that’s really going on for us?
Symptoms may start appearing as indicators that your system is already making some changes to make you vigilant to possible risks: nightmares, visions, flashbacks, lack of focus, excessive rumination, moods swings, heart palpitations, impulsivity, shortness of breath and symptoms comparable to some extent to anxiety. There could also be some symptoms signaling that your system is not dealing well and prefers to lower your levels of response to avoid pain and suffering. Those symptoms look like: avoidance, dissociation, absent-mindedness, easily distracted, self-harming tendencies, confusion, lack of energy and motivation, memory loss, hypothermia (or feeling cold), boredom, lack of pleasure, and symptoms that seem similar to numbness and depression.
If a person has been traumatized or suffered from trauma/PTSD already, the regular symptoms will be exacerbated. Many that were becoming absent may come back. That means that the dysregulation will be more severe and the possibility to feel overwhelmed or defeated is higher. In terms of therapy, clients may be regressing to a previous period in treatment or may feel upset at the therapist, feeling like therapy is not worth it at this point. That could be clear evidence that they are not handling their emotions well and that they are looking for whom to blame. They feel abandoned, unseen, untreatable. The defeat that we may be suffering as a society may feel personal.
To stop the traumatization people need to be aware of the level of stress, the presence of emotions, the origin of the fears and the mechanisms being used to avoid facing the situation. Once you practice that awareness, you will be able to generate a sense of safety, and to take control of your reactions. If you listen to your emotions, they tell you what you need to take care of.
Trauma is a “new” way of conceptualizing mental health. For many therapists, it’s just a diagnosis instead of a new paradigm. It may be an extra challenge attending to the actual crisis for someone not trained on noticing the manifestations of a dysregulation of the nervous system. Should they see for consultation? Or for adjunct work if the client is “acting out” the dysregulation? And even for trauma therapists, should they tell the client about the risk of regression or re-traumatization? Or should they just go back to stabilization instead of continuing the work as it was before the crisis? Hard decisions to make, case by case.
Every emotion, sensation, thought, dream, craving, could be telling us what’s happening internally and signaling that we need to intervene. There are many factors against keeping ourselves balanced and mentally healthy, but still, we can be. Recognizing that a mental crisis could follow the health one if we don’t become aware and proactive is imperative if we want to prevent it. Recognizing that we are all together in this could protect us all and help us achieve better outcomes on a personal and collective level. All we need is to recognize the problem and work on the solutions.
Therapists are going through a lot and they may not be used to monitoring themselves on a regular basis. It’s time to do it. This is a crisis for us too, and even if we are not first responders, we need to respond first. We can help to stop the development of a cultural trauma.
I want to also recognize all therapists that are working in ameliorating this crisis at an emotional level, especially at agencies. Working with domestic violence, sexual abuse, suicide, substance abuse and those extreme responses of people struggling with trauma is a heroic work. Every evening at 7 pm, when I hear the applause and the cheering, I feel like a little bit of it goes to all clinical practitioners. I am extremely grateful for your contribution. I invite you to be grateful to yourself for doing this work.