Uh oh, it’s happening again. Another session where my patient, a man in his 30’s, has taken over the session. I sensed this might be an issue from our first intake visit, which extended into a second session because of our mutual tendency to allow him to speak in long-winded answers. And here we go again – 20 minutes into our session and I’ve barely gotten a word in edgewise. I take an audible in-breath and lean forward in my chair, signaling that I’d like to speak. He responds with a small nod, but at the same time speeds up his words and raises his voice, effectively saying “no” to my bid for a turn. We’ve been through this cycle enough times that I’m feeling rather trapped – my choices seem to be either to shout him down or fall silent. On the one hand, this isn’t a good thing. He’s not going to get any help if he doesn't let me participate in the conversation. On the other hand, falling into this pattern is exactly what needs to happen. He’s come to see me for help with his relationship with his wife, who complains that he interrupts her all the time. I can almost see the thought bubble above his head shouting, “Help! Stop me!”

Healthy relationships offer opportunities for the joy of conversational “flow.” An excellent conversation can have the charge of two soccer players passing a ball back and forth down the field or the grace of a figure skating pair. The two parties read each other’s non-verbal communications, sensing when to move forward and when to shift to support their partner’s motion. In conversation, the “silent” partner is active in the role of listener, sending feedback signals in the form of nods, reactive facial expressions and all of those wonderful listening noises: “uh-huh,” “mmm,” “oh?” “I see,” “yes,” “go on.”

People can fall out of conversational cooperation by either talking too little or too much. Some people offer excessively terse “closed down” answers when discussing emotional content, obliging the listener to work hard to draw them out. Others tend to speak with excessive length or over-complexity, in ways that can be hard to follow and difficult to interrupt¹.

Traditionally, the culture of therapy has been to let patients talk. Psychoanalysts famously say almost nothing. But failing to address conversational imbalance is a huge missed opportunity. Helping patients recognize and shift a problematic default tendency is an important part of therapy – both because conversational collaboration is a key part of the working relationship, and because the therapeutic dialogue serves as an in-vivo training opportunity in collaborative behavior. What is tricky is to do this in a way that is encouraging rather than shaming².

“Allan, can I stop us for a moment?”

He looks at me somewhat surprised, for I’ve raised my voice a bit louder than usual in order to get his attention.

“Sure?” he says a bit dubiously.

“I’ve noticed something happening between us, and I was wondering if we could take a look at that together because I’m thinking it’s an opportunity for us to communicate better.”

“What do you mean?” He’s flinching as if anticipating a harsh blow.

“There have been a number of times I’ve had something I’ve wanted to offer you, but I haven’t been able to find a way to break into the conversation. I’ve noticed feeling a bit frustrated, and also sad because I don't feel as connected to you as I’d like to be. I’m wondering if you’ve noticed this, too, and if you’ve felt anxious or frustrated with how we’ve been connecting.”

I can see him physically expand, as though about to let out a flood of thoughts, but he stops himself. He speaks slowly for the first time.

“I was afraid you were going to criticize me for interrupting you, just the way my wife does. I think I’ve been worried all along that you have been silently judging me, and ironically I think that makes me talk even more so you won’t have a chance to hurt me.”

“It sounds like I was on the mark about your feeling anxious in our relationship – and that you’ve been feeling that anxiety for good reason, because you were picking up on my unspoken frustration. It’s really cool that you noticed that. It feels awkward to talk about this, but at the same time, I’m excited by the opportunity we have to shift things, so we can have a better connection.”

“But I don’t know how to stop interrupting or even to talk less. I don’t feel like you really get me, so I have to give you all the details. Like, I mean…”

I raise my hand and smile. “Is this an example where you wanted to add in more details so I’d understand?”

He nods.

“Could we try something?” I ask, “I wonder if this might be a ‘less-is-more’ situation. Would you be willing to let me guide you a bit? I’m thinking that if you give me a little more space to talk, we might actually communicate better and ironically, you might feel more understood.”

“I already feel more understood since you stopped me to talk about this.”

Together we agree on a plan for me to raise my hand when I’d like to talk so we can practice a more back and forth dialogue. He recognizes that this shift away from telling every story in completeness is going to be uncomfortable for him, but he sees what he stands to gain.
Two sessions later, things are already starting to look different – he’s still a talker, but we’ve gotten ourselves in rhythm, and we’ve gotten down to work tackling his communication difficulties with his wife.

“Wow!” he tells me at the end of a particularly good session. “We had a real back and forth going there. That was actually a lot of fun! I’m so glad you stopped me!”

References
Gratitude to Dan Brown’s work on fostering collaborative behavior (see his book Attachment Disturbances in Adults, Norton, 2016)

Gratitude to Dr. David Burns for his method “Changing the Focus” demonstrated here (see his book Feeling Good Together, Crown Publishing Group, 2008.)
 

“We scheduled his next appointment, and I took payment for the session. I turned to open the door to my office as I always do, and I said take care and that I would see him next week. As he walked past me, he turned back and said, ‘You know, tattoos are a choice, and God did not choose for you to have tattoos.’ He just kept walking. I was shocked. It was unexpected. I didn't know what to say; it happened so quickly and quite literally in passing. It was not in a hateful tone at all.”

So began a spontaneous and unsolicited conversation during my counseling internship class – I always offer students the opportunity to reflect upon their previous week’s sessions, whether seemingly innocuous or salient. In this instance, one of the interns hesitantly brought up a clearly uncomfortable moment at the end of a recent session with a teenage adherent of the Church of Latter-Day Saints. His departing remark took her quite off-guard in the moment and led her to process whether she might have better served this young man by concealing, rather than exposing her tattoos.

What seemed apparent to me was not whether she should or shouldn’t conceal her ink (her agency did not explicitly prohibit exposure of tattoos), but that this was a unique teachable moment both for her and her young client, but also for me, as her clinical supervisor.

I did not want her to roil in shame and guilt over the concern that she might have somehow hurt the therapeutic relationship and this client, leaving him avoidably confused. Had she just covered up! I wanted to create an atmosphere of both acceptance and challenge, in which she could explore the relationship between choices she made as a clinician and person and the impact of those choices, whether intended or not, upon her clients. And I knew the rest of the interns were listening for lessons they could take from the conversation, as they reflected both upon this specific situation and those with their own clients.

In those moments, I was both the supervisor, cognizant of seizing the lessons inherent in that teachable moment, but also the therapist, reflecting on similar moments I have had with my own clients at the self-doubting and shifting intersection of self-concealment and self-exposure. I, too, am visibly tattooed, at least if I roll up my sleeves, which I most invariably do when working with clients, both literally and figuratively. I wanted what I have learned on my road to becoming a therapist to be useful to these nascent clinicians. I also did not want to force them down my road, even if I could.

Over the next week, I reflected on that conversation, wondering about its impact on this particular intern and the group. In the next group supervision, she offered the following:

“Dell [a fictitious name] did come back to counseling, and he actually brought up the subject of my tattoos and his faith before I could even close my office door! He said after he left, he immediately felt bad for the way he approached the subject of my tattoos and that he thought a lot about it and was concerned I wouldn't see him anymore, as he said he enjoyed our time together and that I was incredibly helpful. He said when he left he started thinking about why people get tattoos and what they mean to them. He came to the conclusion that for some people, tattoos are as meaningful to them as his CTR ring (Choose the Right, which is a saying in the Church of Latter Day Saints). He asked if his conclusion about tattoos was true and what mine meant to me. I said that I could not speak for others with tattoos, but that mine meant very much to me.

I described them as time capsules, memories, a reflection of me; stories, and that they mean very much to me, just as his faith does him. I told him there was no need to apologize, and I appreciated his kind words. I also applauded him for taking the time to reflect and educate himself about the subject, as I will not be the only human he encounters with tattoos. I also told him that I thought a lot about what he said and that I researched a lot about the Mormon church, so I could have a better understanding of his views. We agreed that this new understanding of one another strengthened our professional relationship and that we both learned from one another and in working together.”

My supervisee impressed me with her expanded world and self-view, one that was broad enough to take in all visitors to that intimate space of therapy. She closed by saying, “I learned how tolerant I can be, when something I love and cherish is judged so quickly and harshly, and that people have the capacity to grow and open their minds to differences even when their religions may not agree.”

I was honored to be part of the learning process, initiated by my clinical curiosity and desire to guide my interns forward on their own journeys. Indelible impressions were made on all.
 

After the last COVID-19 patient has been discharged and the intensive care unit beds are empty, the world will declare the crisis over. Politicians and pundits will begin to talk about mistakes made and try to lay blame. They will finger point and bluster about why it got as bad as it did and declare it wasn’t their fault.

Store shelves will be full of products again. There won’t be a run on toilet paper or hand sanitizer or sanitizing wipes. People will have parties and weddings. They will have celebrations just because they can. Many businesses that were forced to close will reopen, many people will have jobs to go back to, and nearly everyone will breathe a sigh of relief that it is over.

Family members will gather to mourn their dead, to hold each other and cry, to process the guilt of not being with their loved ones as they died.

Doctors and nurses will start to process their own trauma. The trauma of watching patients die alone, of their decisions about who got the respirator and who didn’t, and of knowing their colleagues died from this virus due to lack of protective equipment. The trauma of holding the phone for a patient and witnessing the last goodbye before that patient is put on a respirator.

Those who survived this virus will wonder if they passed it to anyone else before they even knew they were contagious. Some will know they passed it on, and they will wonder if any of those people died.

Things will eventually get back to the way they were before this virus took over our lives in ways we never could have imagined and barely comprehended

People will enter my therapy office trying to find a way to fit this unprecedented event into their life story. There will be guilt and regret and pain and fear. And grief. So much grief. The trauma will continue for months and years to come because trauma is a time bomb with no visible timer.

The trauma of this pandemic does not end when the acute crisis is over. That is when it truly begins. That is why I am the last responder.

As I listen to the ever-increasing number of infected and dead, I know my work hasn’t even begun. I will celebrate when the intensive care unit beds are empty and when we can hug each other again.

Life will start to return to normal, but things won’t feel quite the same.

I’ll take a deep breath. And then another.

And then, I’ll get to work.
 

Clinicians are currently in the same predicament as their clients. They are struggling with similar pandemic-related challenges, and many of the go-to interventions aren’t available right now due to social distancing. Clients feel isolated and lacking in social support and, while social media offers some respite, friends and family might not be able to offer the client what they need due to their own challenges.

While this can feel a bit hopeless to clinicians, the answer lies not from without but from within: television, once thought of as the bane of social connection, gestures towards part of a potential solution. As long as clients have a television, internet access, video games, comics or books, they are just moments away from potentially meaningful attachments. Parasocial relationships are the one-way relationships people have with objects of their affection — both real public figures and fictional characters. We prefer to call these relationships Fandom Attachments, as the fans are experiencing the benefits of attachment to their celebrity/fictional heroes. These relationships can be incredibly healing. They offer the additional benefit of play — an outlet for the imagination.

There are few positives that the pandemic has provided, but one is the destigmatizing of Fandom Attachments. Culturally, these attachments are often looked down upon as being childish (in the best of times) or pathological (in the worst). However, during this time of isolation, the usual narratives surrounding fandom’s lack of importance, simply don’t hold. Where else can someone go? Who else can they see? The pandemic has given people permission to play in this realm.

But it isn’t sufficient simply to advise a client to go watch television. The awareness of Fandom Attachments might be new to clients and they need support from their psychotherapist on how to interact with this new form of attachment and play. First, the clinician will want to ask clients if there are any fictional characters or (non-fictional) public figures with whom they feel connected. Clinicians should prepare themselves for a broad range of answers. Beyond mortal and superheroic/supernatural figures, some attachments might include YouTube makeup artists, Twitch streamers, reality TV stars, actors, and fictional characters from any media.

Once the client has identified a Fandom Attachment, this is an opportunity for the use of Therapeutic Fanfiction skills. The clinician has the opportunity to become curious about the reasons for the attachment––just like in any relationship. What draws the client to that person/character? What is the feeling they get when they are “together?” How can/does that person/character support them during this time? And, just as the clinician always does, listen without assigning any judgement to what the client discloses. The client is sharing an important relationship and source of meaning. Depending on the answers to these questions, a treatment plan begins to form.

Let’s explore the case of Audrey (name and details changed). Audrey presented for therapy six months ago due to profound anxiety. She was making excellent progress in reducing her anxiety through interacting with friends and taking regular yoga classes. Unfortunately, due to the pandemic, she couldn’t work, and her yoga classes weren’t meeting. She lives with roommates who caused her some distress, but this distress had become intense, as she felt she couldn’t get away from them due to the pandemic. But she felt trapped when she stayed in her room to get away from them.

After some inquiry, I (Justine) discovered that Audrey felt an attachment towards the television series Twin Peaks, and particularly the character of Agent Dale Cooper. Audrey found “Coop” to be comforting and full of sage wisdom, like “Every day, once a day, give yourself a present. Don't plan it. Don't wait for it. Just let it happen.” I wondered aloud if Audrey could give herself the present of time with Coop away from her roommates. This sparked joy for Audrey, who responded that she would love to spend time with him, and that maybe she could have Coop’s favorite meal — coffee and cherry pie — while she watched. I affirmed this and said that we would check in on her “date” with Coop at the next session.

Social distancing and the ensuing quarantine challenges us all in numerous ways. As clinicians, if we can think beyond our scope and get creative with our clients, we can help them use the power of play and Fandom Attachments to foster resilience and weather the storm. There are so many unknowns during this time, but, taking Dale Cooper’s lead again, what we can offer our clients is this: “I have no idea where this will lead us, but I have a definite feeling it will be a place both wonderful and strange.” 

A woman dreams of a knock on the front door and she opens it to find no one there. But something compels her to look down, and there is her son, lying dead. A man dreams of a dragon who is so large and so angry, he has the sense that it will overwhelm not only him, but the entire world. Its shadow passes over him but then grows so large it seems to obliterate the sun… I dream of a woman who jumped up onto a high platform, gracefully and lightly, yet with her balance tipped slightly back. And I watch in horror as she begins to fall gracefully to what I am sure will be her death.

In times of crisis like these, it is very common to have more intense and frequent dreams, and for the dreams to represent our deepest fears about the crisis. So, it comes as no surprise that many people, my clients included, are reporting more frequent dreams of death and of large, inexorable forces, so much bigger than they are.

One of the beautiful counterforces to all of this dread is the wonderful way people are coming together to offer mutual support. For example, on the Jung Platform, an online classroom disseminating practical ways to apply Jung’s ideas, Robert Bosnak is offering a free Friday-night Spooky Dreams Café as a gathering place for those who want to share their disturbing dreams. For an hour, Bosnak has been doing speed-dreamwork with participants and plans to do so for the duration of the crisis.

I offered my dream of the falling woman to the group. She is a friend of mine whose immune system is compromised, so in this dream there is some of my palpable concern for her as she is someone who would likely not survive a coronavirus infection. The dream also put me in direct contact with the feeling of watching a tragedy from a distance, seeing clearly what is about to happen, but without any way to intervene.

Bosnak asked me to embody first the supple and lithe way that my friend leapt onto the platform. And then I was guided to feel into the immense gravity of the fall, sucking my upper body backwards into my chair. I felt paralyzed. As I held both places simultaneously, I felt pulled apart. But in between, in my chest and belly, I felt an opening, and some heat. This is my practice, Bosnak said, to feel that heat.

In my own dreamwork practice, I work in a similar embodied-experiential way, but the steps I offer come from focusing, a practice philosopher/psychologist Eugene Gendlin developed as a way to gently inquire into our own felt sense of any situation. I have applied this method to trauma work and nightmares and have found these steps offer surprising ways to help my clients manage overwhelm and safely metabolize frightening feelings and dream images.

One of the ways to work with dreams in a focusing way is to embody the helpful images in the dream as a resource, in much the same way we help our trauma clients become resourced before going into any deeper work with their trauma. For example, with the man who dreamt of the dragon, I asked him to imagine he was the dragon, and from that vantage point, he was filled up with immense power and agency. And, as I often do with nightmares, I asked the dreamer to continue the dream from where it left off, as if he pressed the ‘play’ button on the final dream image. Typically, nightmares wake us up at their most frightening place. In this imagined dream ending, the dragon began to fly higher and higher until its shadow was a mere speck on the surface of the earth.

Imaginal ways to manage overwhelm

The overwhelming sense of powerlessness is a common dream theme right now because it is how so many of us are feeling. One thing that we often do in focusing, whether with day-world feelings or looming dream images, is to find a way to make them smaller, more manageable. We might find the right distance from our dream dragons (i.e. much further away) or shrink them down to the size of a mouse in our mind’s eye. What we are feeling in response to the coronavirus is a sampling of the collective dread, and this is more than one person can ever manage. Another way to work with such images is to ask clients to sense how much of what they are feeling belongs to them alone. It is usually a much smaller piece.

One more way of titrating the enormity of a crisis is to limit it in time — to just this present moment and the next one. For example, when I sensed into the immediate feeling I had about the helpless sadness in my falling-woman dream, seeking the right next step, it was clear what I needed to do. I called my friend and was reassured that she is fine and being extremely careful not to expose herself to any risk. I have also felt moved to use my particular skill set to help reduce some of the collective dread. I wrote an article for first responders (and anyone else suffering from nightmares) with some suggestions about what to do. I have opened a number of dream sharing groups and remote therapy sessions for front-line workers. I am using the ways I know best to help reduce collective anxiety one person and one dream at a time. The fire in my belly, borne of helplessness and fear, is being put to good use. And the man who dreamt of the dragon said his dream has changed, and now the dragon is a sentry, watching for early warning signs.
 

 In the 90’s, Scott Miller and Barry Duncan developed the Client-Directed, Outcome-Informed approach to psychotherapy (CDOI). More recently, Miller along with other clinicians and researchers, developed Feedback-Informed Treatment (FIT), while Duncan developed the Partners for Change Outcome Management System (PCOMS). These innovations in the field center on the idea of understanding and honoring the client’s voice; to understand how they are experiencing the therapeutic process and relationship and to give them agency over the course of treatment. This body of research demonstrates that client feedback increases retention rates and improves therapeutic outcomes. The implication of this new research, for those of us who want to provide best practice to our clients, is to leave the beaten path of rigid model adherence to be client-directed and feedback-informed. Understandably, this may not be as easy as it sounds.

For some clinicians, leaving the useful guardrails of model adherence may feel like following a rabbit trail. After all, we are practitioners of evidence-based models, models shown to be effective in producing positive outcomes for clients. Many of us were taught in graduate school that best practice is synonymous with model adherence. It is the model and how well it is delivered by a clinician that heals people, right? Hubble, Duncan, and Miller discussed the eye-opening common factors of their research in their book Heart and Soul of Change. They showed that the psychotherapy model only has a minimal impact on client change, as opposed to the therapeutic alliance and extra-therapeutic factors, which have the biggest impact. By way of implication, we must consider that clinging too tightly to a model may not ultimately serve the client. That putting all our eggs in the model basket may not constitute best practice. That we need to follow a client when they stray from the path — to follow a rabbit trail — in order to discover the true nature of their issue. And that we need to embrace rather than shy away from the paradigmatic tensions between rabbit trailing and model adherence. How can a therapist hold the reins of these two stallions running in opposite directions and not be torn asunder?

Advantages

What are the advantages of rabbit trailing? A client may need to rabbit trail so as to feel in control of the therapeutic process. We want our clients thinking, “This is MY therapy.” We certainly do not want clients thinking, “This is HER therapy.” Treatment is enhanced when clients feel a sense of ownership over the therapeutic process.

It has been my experience that a segment of clients seeking therapy do not know the nature of the problem that is holding them back. Therefore, a journey of rabbit trailing and discovery is necessary in order to identify the true nature of their problem. Additionally, clients’ initial presenting problem may indeed be a genuine problem, but not the true or core problem. Again, rabbit trailing may be necessary to explore the depths and discover what is holding them back.
Rabbit trailing also feels very organic. Think for a moment how odd our profession is. We sit in a room waiting for people to come and tell us their problems for a concentrated period of time. The relational dynamics active in counseling are unlike anything our clients experience in their daily lives. So, if the counseling process could feel more natural and organic, and less artificial and cold, all the better. The relationship between client and therapist can develop; you and the client are in the dark, together, searching for the answer that is right for the client. Rather than a regimented process where you are doing something to the client, rabbit trailing is an exploration, collaboratively done by client and clinician.

Rabbit trailing allows for issues of the “here and now” to be addressed. If strictly following model protocol, a client’s true issue may not be addressed till session 5, or 6, or 7. Clients may not have that kind of time. Or, rather, they may not stick around for you to get there. And, to be honest, a single model may not be enough. Rabbit trailing allows for other models to be integrated into the course of the treatment as it seems useful and appropriate for what the client needs in the moment.

Cons

What are the disadvantages of rabbit trailing? Some clients may need the regimented approach and may not do well with rabbit trailing. We’ve probably all had those clients who show up for session and look at us, waiting for us to “do” therapy. And hey, I get it. Between patient and physician, that’s kind of how it works. The patient shows up, and the physician does something to them to make them better. There’s a logic to the approach that’s carried over from the healthcare system, and I’ve done it too. So, if that’s what the client wants and needs, then let’s give it to them and walk them through the model.

Rabbit trailing could certainly devolve into weekly check-ins, versus working on something substantive. There is a place for a systematic, step-by-step approach, otherwise, therapy could deteriorate into putting out fires and never truly working on the issue causing the fires. In other words, rabbit trailing could fall prey to chatting and socializing rather than doing serious clinical work.

Rabbit trailing may lack consistency and accountability. For example, with the model adherence approach, there is assessment, intervention, homework and exercises, and then follow up. If a client didn’t do their homework, rather than getting distracted or moving on to a new topic, the reasons why they didn’t do the homework need to be addressed. Addressing those reasons could enhance treatment and client outcomes. With rabbit trailing, you may be ping-ponging issue to issue, week to week, and not keeping clients accountable.

Sam

A father brought his 15-year-old son, I’ll call him Sam, regarding concerns of depression and anxiety due to his divorce with his wife. Sam, he didn’t have much to say about his parent’s divorce. He felt like it happened a long time ago and it didn’t really bother him. He felt like no one believed him and he didn’t have much else to say. Sam seemed uncomfortable and was slow to open up. As sessions progressed, I felt the urgency to connect with Sam and make it comfortable for him to share. I remembered Sam mentioning he wanted to buy and fix up a car. I asked him if he had bought a car yet, and he said he had and was planning on fixing it up, but it would cost a lot of money to do so. He went on to say he felt conflicted; he wanted to get a job to earn money for the car, but that would mean he couldn’t play sports, which he felt okay about because, even though he loved sports, playing in front of other people overwhelmed him with performance anxiety. We weighed the pros and cons of both options and concluded that Sam really wanted to play sports but was paralyzed by performance anxiety. I mentioned to Sam that I had a number of ideas and strategies that could help with his anxiety, at which he became very excited. From that point on, Sam was open and engaged in therapy. Following Sam’s rabbit trail led to the discovery of his performance anxiety and his hidden motivation to resolve it. I was then able to utilize CBT and standard methods to effectively treat his anxiety.

Holding the Reins

Hopefully, weighing the pros and cons of rabbit trailing has answered the question, is it possible to hold the reins of BOTH model adherence and a client-directed/feedback-informed approach? I believe an awareness of the upsides and downsides of both model adherence and a client-directed/feedback-informed approach will allow us to synthesize the best of both worlds. We can operate from a model, loosely, and allow for clients to stray from the beaten path when they need, bearing in mind clients’ need for accountability.
 

A few years back, I remember being deeply impacted by Richard Louv’s “Last Child in the Woods: Saving Our Children from Nature Deficit Disorder.” In it, he lamented the disconnection between children and nature, reflected on the impact of that disconnection on not only children but adults, and offered corrective suggestions. His book resonated with me, as I have, since as far back as I can remember, found comfort, grounding and meaning in the natural world. From early childhood, I seemed to understand the importance, power, beauty and violence of nature – both physically and metaphorically.

This understanding often informed my teaching and clinical practice, whether it was explaining reproduction to students by observing it in the lush woods surrounding my university, or discussing life, death and the cycle of being by accompanying clients on nature walks. Invariably there were lessons abounding in the trees, the sky, the animals we might accidentally encounter along the way, and in the rich and symbolic discussions we had around issues related to birth, death, divorce and aging. Metaphors accompanied us on those walks, and with them opportunities for painful and pleasurable but always poignant insights.

These experiences came rushing back to me recently when, on a hike through the woods along the Blue Ridge Parkway in North Carolina, I once again pondered deeply about the natural world, and my place in it. I couldn’t help but notice that although the trees and shrubs were gray-brown reminders of yet another brutal mountain winter, all were at the same time in bud, with the local birds busily building their nests and feeding their young. Several days before that walk and upon our arrival, it was 78 degrees, and the local teens were cliff jumping into the frigid river below — in bathing suits. Two days later, there were 4 inches of snow on the ground. It is now back up to a welcoming 60 degrees. The schism and dynamism is dramatic and inescapable. The promise of life and rejuvenation is everywhere. As Jeff Goldblum’s character in Jurassic Park said, “Life will not be contained.”

In these moments of existential absorption and awe, I am not quite able to free myself of the very reason for my mountain hermitage. It was to seek higher ground, quite literally, from the densely populated and sweltering heat of South Florida. Surely, the virus would not find us here.

While my body, as far as I know, has not been impacted by the COVID invader, my mind is not free of it. I am well aware of the suffering this pandemic has wrought, and that countless others do not have the luxury or the privilege to escape to higher ground — of any sort. But there it was, my perfect metaphor! Life abounding in the very same world racked by so much suffering and death.

Is it hope that springs eternal or that eternity is to be found in Spring, a time of nature’s rebirth? How perversely ironic that, in the Western hemisphere at least, this scourge coincides with nature’s reawakening.

I don’t delude myself into believing that thoughts such as these can heal, but in those moments in the woods, I felt hopeful and wondered if there could be a therapeutic value in connecting others to nature during this most difficult time. We have all been advised to stay home and safe, going out only for essentials and, when and where possible, exercise. What if, just what if on those walks we are being asked to take, wherever they may be, we look for it! Look for signs of Spring. A weed pushing up through cracks in the cement, buds on a plant thought long asleep or even dead, the dance of clouds in a blue sky, the breath of warm air in an otherwise cool breeze, the warmth of the sun, the cleansing rain.

My rose colored glasses have long ago been trampled by the passage of years, and I am no longer in the prime of life, but I do look ahead and I do look to Spring and I do think about tomorrow and hope that this musing is useful for you in some small way, whether for yourself or for your clients who are struggling to balance meaninglessness with meaning, death with life and despair with hope.

Spring, and with it, hope, is there. Look for it! Nature will not be contained, nor will human nature.

In the current climate, shaken by the COVID-19 pandemic, therapists, like other professionals from the mental health field, are scrambling to adapt to the sudden transition of their services online.

Battered by this frenetic rush, many therapists may feel reluctant about the move. The pressure and an impending sense of urgency do not help the transition, which would otherwise be achieved over a longer period and in a more natural way. The Loss of the Couch, which I started implementing a decade ago (I am still well, thank you!), can feel more painful and frustrating: it happens in the middle of other losses that the pandemic has thrown at us.

Stoic philosophers — as timely as ever — taught us that the obstacles that we encounter are actually fuel for action and change. Marcus Aurelius wrote that “the impediment to action advances action,” and “what stands in the way becomes the way.” In other words, every crisis is an opportunity, and in every problem there is an element of a solution. Why not face this crisis-imposed transition in a stoic way?

What can help you turn this crisis into an opportunity for you and your clients?

• Re-focus on the relationship. If you believe in the centrality of the therapeutic relationship, you may wonder whether it works online in the same way as it does in person. The good news, recently described by Mick Cooper, is that it does. As you negotiate this transition together with the client, it is natural to refocus on your relationship. Moving from the physical room to the screen is like changing the lens on your camera — from a wider angle to a close-up lens, that remains static, unlike the usual ‘shoulder camera’ effect of the normal human eye. The acuteness of the face-to-face closer shot may surprise you at first, with its unexpected intimacy. Why not use it for an active exploration with your client?

• You and your client are both having to deal with the same major crisis. In normal circumstances, the client is the one bringing up an issue and the therapist helps her to cope with it. This time you are in the same boat. This unprecedented situation has a rich modeling potential. How you are dealing with this extraordinary situation will offer your client some information about you as a person, but also a precious example of how to cope with a crisis. This is a good time to think about self-disclosure. What information about your handling of the crisis could be useful to your client?

• Another side effect of the transition online is the sudden shift in the power dynamics. In the traditional therapeutic setup inherited from psychoanalysts, sessions take place on the therapist’s premises. He has all control of the surroundings, chooses the disposition of the chairs (and therefore the distance between him and the client), the lighting, water, tissues… Online, this power is equally shared with the client. Each party has to make the same kind of choices about where to sit, how to position the camera and the light, what to drink. In addition, the client can make you disappear with one simple mouse click. This sudden redistribution of power, if addressed properly in therapy, can be extended to other client’s relationships and eventually become a source of empowerment.

• Yes, in this transition we are losing the couch, as well as the possibility to offer our clients tissues and a glass of water. But as a compensation, it also brings some new sources of additional data. In the traditional setup, the client comes into your universe, or at least the one you created in your therapy room. By connecting in an online video session, you literally open a window into your client’s physical realm. This is a new source of valuable information otherwise not available to the therapist. Pay attention to where your client chooses to bring you — which part of his life he shows, and make the most of this rare access.

• We all know how crucial the first session is. This is when we first engage with a new person, discover how it feels to be in the same room with them, hear for the first time about their life. Usually, we have only one shot at it. But your first online session with your old client will be a renewed first experience. This is a brilliant opportunity to shift the focus to the here-and-now and, maybe, even ask the questions that you were a little too tired or too settled into your shared routine to ask before.

• The so-called online disinhibition effect addressed by John Suler in CyberPsychology and Behavior¹ can propel therapy forward. When meeting online, clients do bring up important material more quickly and discuss difficult, shame-triggering information more readily. The therapist has to be prepared to take it on, not to shield away from this unusual immediacy facilitated by the medium.

The pandemic is also a good time for things we have been postponing forever and ever. The kind of advice we generally give to our clients works for us as well. Consider peer supervision or an online peer support group, reflexive practice, or training in some area worth improving. Reach out to an expert in the field. Exploring the online medium within a safe peer relationship, especially if it is new for you, will help you get more confident and efficient in using it with your clients.

Once this acute crisis is over, many therapists will return to their therapy rooms, relieved to be reunited with their clients in the same physical space after a prolonged confinement depriving us of touch and smell senses. But many, once adapted to the new ways of connecting, will want to maintain some part of their practice online. After all, it will have allowed them to keep helping their clients during these difficult times.

This is an opportunity for the profession to catch up with technology and make therapy more widely available for those who are displaced, have a restricted access to healthcare, or who are just reluctant to come in person. The wisest of us will improve their skills and become more agile online to help their clients even more.

References

Suler, J. (20-4). The online disinhibition effect. CyberPsychology & Behavior, 17(3), 321-326.
 

We are therapists. We’re the healers, the modern-day shamans who have taken millions of people on heroic journeys of self-discovery. We have treated the wounds of countless individuals, couples and families, and have provided invaluable assistance for people to lead better lives, love themselves more and become the best versions of themselves.

And now, due to COVID-19, we’re seeing something new. Beneath the rubble of our seemingly collapsing culture, we are also simultaneously seeing an increase in introspection, self-reflection and the very pace of therapeutic movement. Before I discuss these hidden opportunities of the pandemic, I’d like to mention a phenomenon that I’m seeing among therapists and patients: We are all along a non-linear spectrum in relation to the impact of the coronavirus. Here are the phases I have noticed:

· Shock, with a big dose of despair and incredulity
· Panic – hoarding and fear of becoming ill and dying
· Dealing with fundamentals and the Big Adjustment

Where do we shop? At the store, online?
How to set up the home office? The home school?
How do we re-divide chores?

· Settling in – it takes weeks to establish the new normal
· Questioning our values, choices (including our spouses), and behavior
· Seeing the opportunities for growth, maturity and change

In the recent past, I have seen couples talk about important, formerly ignored issues. They are aligning their priorities and seeing the bigger picture, overlooking “the socks on the floor” naggings and replacing them with gratitude and a greater generosity of spirit toward one another.

Couples with children are eating dinner together, in some cases for the first time in years. I asked one couple, who is walking more, to each take one of their two children on walks. I suggested: Get to know them better and give them the opportunity to know you. Tap into your strength by giving them guidance but acknowledging your own fears and concerns. Attune to them by validating their feelings – whether that it’s a good thing for mommy or daddy to be home more often or the terror at the thought of what might happen to them.

In my work with individuals, I’m witnessing how most of my patients are questioning their values and way of life. They wonder if they’re treating other people fairly and are seriously considering the fact that they have seen people as objects to gratify their own needs. But now, even the more narcissistic patients are contemplating that “where object was, subject shall be.” Now they’re expressing the desire to meet their own needs and at the same time consider other people and their needs – Adler’s notion of enlightened self-interest.

These individuals are questioning their motives, looking at their actions, and are introspective on a scale that I have never witnessed in my 28 years as a therapist. And there are metaphors and ideas that can be incorporated into your practice to help patients to grow and change.

Infection as a Metaphor

Infection and the concomitant need for physical safety is a growing concern for many. One patient wants to get a home alarm system – he’s worried about “other,” and, at a time when crime rates are going down, his fears are, at least in part, a concretization of a metaphor.

Wearing this lens, I asked my patient – as you can ask yours – "If you’re feeling a lack of physical safety, could it be a metaphor for a lack of psychological or emotional safety? What are some other areas where you feel vulnerable? What is the nature of the perceived or actual threat? Have your boundaries been violated, and if so, what did you, your partner, or your parents do about it? Were they the perpetrators?"

Hoarding as a Metaphor

I have been working with patients who hoard to look for the metaphorical aspects of hoarding; a mirror of living amid refuse and/or the safety of “things”. When they have been faced with challenging experiences in the past that involved an element of helplessness, fear, and uncertainty, what have they done to maintain a sense of control?

The over-buying that is happening as a result of the virus can be used to gain a greater understanding of the DSM diagnosable hoarders in our practice. With our own fears of not-enoughness (I didn’t buy 24 rolls of toilet paper until I saw that others were doing it), we can develop greater understanding and empathy for the fear, panic and concern that our hoarding patients feel every day: Not having enough protective stuff. We can honestly tell them that we understand the terror they feel about possibly losing the security of what envelopes them. We can now more fully understand their responses.

The metaphor of hoarding can also be applied to the newly-hoarding individuals who are collecting their water, toilet paper and Purell. If they’re insecure or untrusting, do they obsessively geo-track their spouses or go through the history of their spouses’ phones? Do they covet their friendships to the point where they’re threatened if two mutual friends get together?

Educate your patients about concretization and at the same time show them empathy – that although hoarding ostensibly looks like the need for more material objects, to hoard is an attempt to feel safe, even if those objects prove elusive in providing safety.

Encourage Negative Capability

This time is also an opportunity to help patients learn to have a greater capacity to tolerate ambiguity. It’s what the poet Keats called “negative capability,” which is the ability to live with uncertainty. For those patients, I ask them to live in the question and find the liberation in helplessness. The latter concept means that patients, when faced with a high degree of ambiguity, can either panic and wail, “What can I do?” or they can let it go and say, this time with a shrug, “What can I do?”.

Support Transformational Experiences

This may very well be the perfect time to help patients understand their wish for a “transformational experience” – that thing outside of themselves that they think will make them happy – to be the folly that it is.

Until now, people could fool themselves with this anticipated metamorphosis of “I’ll be happy when.” I’ll be happy when… I get my driver’s license, when I’m married, when I have kids, or when I’m rich.

Sadly, the only patients who already know the falseness of this notion are those who were not changed by these experiences. The wealthy, for example, are the only ones who truly know that money can’t buy happiness. Sadly, many patients still seek changes from the outside rather than from within. This time period may be the window that just opened up to help our patients understand what a true transformative experience is. Ironically, it is this virus and other crises that ARE potentially life changing. And we have a golden opportunity for radical transformation among our patients.

Find Meaning

To extend our capacity for healing, use the knowledge that human beings are meaning-makers. Some patients may unfortunately view the virus as the cop on the side of the road – the one they slow down for but begin speeding up once the motorcycle is no longer visible in the rearview mirror. Or we can use this disease to help our patients to change in a more focused, accelerated way.

Many of your patients may not be ready to hear this. But it’s a way for you to approach the material. What matters now is that you are ready, because we need to help people make positive meaning out of this crisis. To that end, I suggest the book Man’s Search for Meaning by Viktor Frankl – a survivor of Auschwitz – for you and your patients to read.

Prepare to Help Patients in The Future

Yes, this virus is awful, isolating and devastating. But these hidden opportunities can create greater connectedness, compassion and insight.

Millions of people will emerge from the rubble of our former culture in need of our assistance, whether it’s from depression, anxiety, life-changes or post-traumatic stress. They will need us, and we will be there for them.

We are the Healers, the alchemists who can turn this tragedy into an opportunity for growth. Caring, compassionate individuals make up a compassionate society. And we’re in exactly the right profession to make it happen.