Global Pandemic! These frightening words have changed lives and livelihoods in countless ways. For some, the resultant isolation is intolerable, while for families and roommates cooped up together, alone time is sorely missed. Anxiety rules the day for many who are uncertain if they will have funds to cover rent, mortgage or food. Medical advice and warnings, some sound, some not, fill airwaves and social media feeds. We are all being challenged to be creative in how we spend days that seem to morph into each other, and the calendar has become a good friend. We are living in an invisible society of bare grocery shelves, boulevards absent of pedestrians, and identities hidden behind medical masks.

Many of my clients, like those of so many of my colleagues, had already been struggling with anxiety, depression and existential angst pre COVID-19. Now they have the added burden of trying to cope in a fear-laden world – a world that for many seems to be spiraling out of their control. Working with clients to find areas of their lives they can still control has been extremely valuable to them. Teaching people relaxation and breathing exercises, encouraging connectivity via video platforms, phone calls and texting, and emphasizing the importance of physical activity has also been helpful. I suspect that many of you are utilizing similar techniques. What I have been noticing, however, is that the focus of sessions has varied across client populations.

What weighs most heavily on my more senior clients is fear of contracting the Coronavirus and ending up hospitalized or isolated in their homes. Deciding which family members, close friends or trusted neighbors they’d feel comfortable reaching out to in an emergency has been part of our work. But for a handful of others, there’s the frightening realization they’ve lived their lives without an adequate support system. Some clients have yet to create a will or DNR order. For these particular patients, end of life plans were not a subject to be broached with loved ones, let alone thought about. In our sessions, we have begun the hard task of working through their discomfort.

A large part of my practice is devoted to working with ethical vegans. These clients are finely attuned to the suffering we humans inflict on non-human animals. While the actual origin of Covid-19 may never be agreed upon (bat, Pangolin, or other animal), there has been lots of speculation that it originated in one of the wet markets in the Wuhan Province of China. Video footage of these outdoor markets, where diverse species are trapped in tiny cages or crammed into dirty pans of water, is being widely circulated on social media. Seeing these suffering creatures, which reminds my clients of the many animals living in wretched conditions on our factory farms, has been extremely triggering. Additionally, with so many people being laid off from their jobs, my clients are concerned that people may decide they can longer afford to keep their animal family members and will resort to abandoning them at shelters or worse, on the streets. Relaxation and visualization exercises, as well as a good deal of venting, have been a big focus with this population. Identifying actions they can take to help animals has also been key, and some have decided to foster a dog, cat, or rabbit or donate money/supplies to the many animal organizations now in dire straights.

Another sector of my client base are those people with children, and concerns vary depending on the child’s age. Those with younger children are reporting being very overwhelmed with having to home school, work remotely, and stay on top of household chores. Clients with college-age kids are now dealing with young adults who have gotten used to calling the shots in their lives. They may have returned to childhood bedrooms, but they’re far from eager to return to childhood routines and restrictions. Parents who were beginning to adjust to their empty nests and clutter-less spaces are once again contending with towels strewn across bathroom floors, laundry baskets piled high, and diminished privacy. For these clients, creating boundaries and house rules has been essential. I’ve also been emphasizing the importance of alone time, which of course is much easier to implement for those living in houses or large apartments, where doors are now prized. While time alone in smaller spaces is more challenging, setting up a daily schedule where for a specified amount of time each family member won’t be disturbed can be an alternative.

Whether client or practitioner, we can get through these trying times with a little creativity, a lot of patience, and a mantra of, “good enough.”

Joan comes for therapy at 60 because she feels lost and unsure of herself. Mary Jane sits in my office because she is sad and wishes her marriage of 30 years hadn’t ended. Corine feels bad about her body and finds her menopausal hot flashes unbearable. Lulu is depressed because she’s made mistakes in her life and doesn’t see anything changing.

Psychotherapy dictates that I take their histories, assign diagnoses based on their symptoms, mine the past for the cause of their distress and, if appropriate, use cognitive behavioral skills to examine and manage their thoughts and emotions.

But what about creating new lives that Joan, Mary Jane, Corine and Lulu can grow into?
What might that look like? And who or what does one grow into at 50, 60 or 70 years old?

There are very few psychological theories addressing the developmental stages of life from 50 until death. The ones that do are vague and need updating. There seems to be a lack of imagination about what we can expect from life between “grown-up” and death.
There’s even more confusion about the role of psychotherapy when it comes to aging. Years ago, when my husband was in his mid 40s, he was told by a psychoanalyst that he was too old for therapy. Supposedly his development was over, and his psyche was too fixed for change.

How do we help clients understand and navigate the experience of aging if we don’t understand it ourselves? Recently, at 61, I considered doing another round of therapy myself. My wish was to evolve, perhaps transcend. But all that was offered to me was more digging into my past to “figure things out.” I don’t want to figure out that which has already happened. I want to figure out what to do and who to be next. Beyond symptom amelioration, what is therapy for? Is it just to fix? And why does it seem to always turn to the past?

Imagine a therapy for older adults that is future-focused and creative. What if therapy were more like art? A culture without art would be stuck and unchanging, doomed to repeat and remain fixed in the already known. A culture without art limits our unique potential. To infuse psychotherapy with the spirit of art is to make it about creating instead of repairing — keeping it future-focused and more than a review. Here are four bold challenges for psychotherapy with aging clients.

We need new visions and roadmaps for the stage of life between grown-up and dying.

What it can mean to be an older adult needs a radical reformulation and new, diversified visions. Our life spans have increased by about 40 years since 1900. This longevity supplies us with the opportunity for one or more life stages to make meaningful and of value. This requires psychotherapists to use their imaginations. If we are going to hold the space for others to think outside the box and reinvent what it means to age, it’s just as important to flex our own thinking, confront our own ageism and encourage beliefs and actions that shine light on paths not yet worn. In The Big Shift, Mark Freedman calls life stages “social construction projects.” He goes further to say, “What’s abundantly clear is that life stages don’t just emerge… They are… big projects requiring vision, language, leadership, institutions, and often social movements with multiple thinkers dissecting the same key questions”¹. Psychotherapists can have a critical role in constructing new life-stage possibilities for clients to live into.

Psychotherapy that focuses on the past is not enough to help us evolve.

Our stories, our memories, our experiences can serve our futures. We use the present to pull through the threads of our past lives and weave a fabric that will make something new. If we want to make change, if we want to evolve, we must look forward and stop trying to revisit and reset an elusive past. We are prospectors by nature. Martin Seligman in Homo Prospectus explains we are not doomed to repeat our pasts over and over. We are not stuck in stasis until the past is changed or until the traumas are resolved. Instead, we are creators of what lies ahead. We are activators, activists and authors of what is next. A psychotherapy that engages clients as makers rather than reactors will open doors to what else is possible for us all.

Individuals 50, 60 70, 80 and beyond would be best served with a psychotherapy that is future-focused.

Does this really sound so outrageous? Do you automatically think it makes more sense to serve older clients with a therapy that sums up the past and wraps up the narrative? Putting the affairs in order, so to speak. While reviewing the past as an exercise is indeed satisfying and can be beneficial in so many ways, wouldn’t it be much more potent if it included a future-focused purpose? The story is not over, after all.

A recent public health study by the Journal of American Medical Association (JAMA) demonstrated that subjects over 50 with a strong purpose lived longer and experienced better overall well-being. Purpose is future driven and motivates action and growth. To be alive is to grow, until we take our last breath. Psychotherapy could serve to enrich lives and extend longevity via a future-focused therapy.

All the above could be achieved by reconceiving psychotherapy as art (and not just a science).

In Art Thinking, Amy Whitaker says, “If you are making a work of art in any area of life, you are not going from a known point A to a known point B. You are inventing point B. You are creating something new — an object, a company, an idea, your life — that must make space for itself”². To socially construct new possibilities for individuals 50 and beyond, we use our imaginations, write new scripts, practice alternate identities and encourage bold action. Reimagining psychotherapy as art becomes a process and not just a product. It becomes and serves the process of becoming.

Joan’s therapy could be a design project. She can imagine her future self, strategize and act to become her. Mary Jane’s 30-year marriage is over, but Mary Jane is not. Her grieving can include dreaming and crafting a new identity and direction. She can rehearse new ways to be in and see her world. Corine’s menopausal symptoms are painful and disruptive. We can identify them as a portal for transformation and a new stage of life. Corine’s therapy can focus on locating her physical struggles in a narrative that gives them meaning and momentum. And Lulu’s regrets, even the devastating mistakes, can be composted and re-composed into a rich story that provides self-compassion and universal acceptance of our human experience.

Together, as a culture, with our clients and with each other, we can move from stuck and confused to innovators who create a new vision in the space that our longevity provides.

References

(1) Freedman, M. (2011). The Big Shift. Philadelphia, PA: PublicAffairs.

(2) Whitaker, A. (2016). Art Thinking. New York, NY: Harper Collins.  

Whenever we invoke the archetype of “home,” we are expected to conjure up Hallmark scenes of happy families sharing a bountiful meal together. Unfortunately, this is a far cry from reality for many. Social distancing, along with hand washing, is the best course of prevention the medical community has to offer at this point in time. These practices deserve and require our full support to promote physical health. But a close cousin to social distancing, social isolation, is the antithesis to supporting mental health.

Social distancing is defined as staying a minimum of 6 feet apart from others. Social isolation, on the other hand, is a psychological state of mind. It can occur when people are alone or in a crowd, with strangers or family. Whenever and wherever we can’t reveal our true feelings or don’t feel safe to share our thoughts, we are socially isolated. The mental health ramifications of social isolation are well documented. But in these unprecedented times, a much larger group of people are at risk of suffering from this condition.

For my patients who live alone, there is concern for both their mental as well as physical health. One patient, a physician, is a young, healthy woman who has created an independent life. This view of herself is an important part of her self-esteem; but her denial that she herself is at high risk for getting the virus is impeding her decision-making. During our last session, I repeatedly pressed her about what she would do if she got sick. Although she was seeing patients in the hospital too sick to get up, she couldn’t imagine being in that condition herself. Her only plan was to order delivery to the lobby of her apartment building to retrieve takeout food or medications if she needed. By the end of our session, I had her name three people who she would call and ask to be her emergency contacts. Her homework this week is to connect with each of them and ask if they are willing to serve in this capacity.

But those living alone are not the only ones suffering from social isolation. I have patients stuck in dysfunctional marriages; others are estranged from their roommates. Many young adults have moved home, to everyone’s dismay. Injunctions to stay home fail to acknowledge the harsh reality that for some people, home is where they feel most isolated.
One patient who lives apart from her husband, within their home, now finds herself at home with him all the time. She asked him, “Can we put aside all the ways we’re not who we want each other to be for the time being?” He has been depressed for years and unwilling to get help, but she feels a renewed sense of responsibility to look after him during the pandemic. For privacy during our session, she sat in her parked car. She wonders if “the door will have closed” for her to move forward with her own life by the time the pandemic is over.

A number of my patients have moved their sessions to early in the day so they can talk while their children are still asleep. One patient, a mother of two young children who is barely speaking with her husband, locked herself in her bathroom with the fan running while we spoke. She was afraid to ask her husband to take time away from his work to watch the children for an hour.

I am particularly worried about the families I know with children living at home who used to be in residential educational settings. Oftentimes these children need a level of care that is beyond the capabilities of the parents, especially if the parents are expected to be working from home. Families living with special needs children face extreme challenges. One patient in this situation is working from home, and so they are all living in close quarters. We talked about how he needs to stay aware of his anger and to find outlets like physical exercise before he loses his temper. Feeling uncomfortable around his own child makes him depressed and disappointed in himself. If financial worries pile on top of this situation, I fear it could become explosive.

To complicate matters even more, in many homes there is a disturbing new reality, where adult parents are working (often from home) and their young adult children aren’t. Home from school, taking at most a few hours of online classes a day, disappointed to have lost out on a spring semester or graduation, waiting for summer or permanent jobs that may never materialize, they are facing an economic downturn which is disrupting normal developmental milestones. Their sleep patterns are often opposite those of their parents. Negotiating time spent on screens, chores that need to be done and rules of behavior are challenging in the best of times. Although the physical space may be the family home, oftentimes it is not the place these grown children think of as home anymore. Taking directives from their parents is an affront to their own budding, developmentally appropriate independence.

One college senior I work with called in tears from his parent’s home. One week earlier he had been living in an off-campus apartment with his two best friends, planning a spring break and interviewing for jobs after graduation. Now he is home, connecting with his friends remotely and trying to avoid his parents as much as possible. They are working from home and were forced to cancel their own travel plans. I counseled him not to view his parents as the source of his disappointment and sadness. In time, I may do a family session to help with communication patterns in the home. This never would have happened had his college years ended as expected.

A patient who is in the food industry has already been laid off and her prospects, once very bright, now look dim. Her parents, who were never supportive of her career aspirations, are pressuring her to move home to save money. In tears she told me, “To move home now makes financial sense; but I fought so hard to leave the first time, I’m not sure I’ll have the energy to do it again.”

As the consequences of the pandemic worsen and the financial fallout continues, many people are at risk for losing the actual place they call home. These legitimate worries are worse for those already without a strong financial foothold, but by nature of a pandemic, no one will be completely spared. As one patient said, “My sense of peace has splintered. I am looking for a way to reground myself.”

To move forward wisely in these uncertain times, it is imperative that we recognize how we can help each other. We need to combat social isolation just as fiercely as we practice social distancing. By reaching out through phone calls or virtual visits, standing 6 feet apart at the end of a driveway, whatever it takes to strengthen our interconnectivity.
People with heart issues are at greater risk from Covid-19. We should expand that category to include all those whose hearts are suffering emotionally. None of us know how long we will be home, nor what home will look like when we are finally free to leave. If we increase our social connections, be it within or outside the house, we may lessen the heartache of those suffering isolation.

The pace of change that we have all experienced since the pandemic began has been both staggering and destabilizing. In the span of two weeks, I went from running a full-time, successful private practice in a beautiful office to doing video sessions on my phone in my poorly lit basement. The logistics of the transition aside, my pervading sense of anxiety, worry and deep sense of loss have made it increasingly difficult to focus. I careen between my roiling emotions in search of a ballast, something to give me hope that normalcy will soon return.

March break is a slow period in my practice, and I had been looking forward to an increase in clients (and income) when the World Health Organization declared that the Coronavirus had been classified as a pandemic. One of the first things I noticed was the cancellations spreading across my online booking system. There was also a nearly complete cessation of new clients contacting me. Within this unsettling context, I had to figure out how to transition my practice from face-to-face to online therapy in a matter of days. I had thankfully been using a software platform that allowed me to conduct secure video sessions through my existing client portal. I emailed my active clients and reassured them that I would be there for them and that therapy would continue, though strictly through a screen for the foreseeable future.

Before COVID-19 struck, I had been resistant to accepting clients who only wanted online therapy. I was worried that I wouldn’t be as effective, that the alliance would be harder to establish, and that I wouldn’t enjoy the work as much. While I am still acclimating to doing sessions on my phone, I have been pleased to see the familiar markers of a good therapy session: clients expressing emotions, gaining insights, and developing new patterns of thinking and behaving. I still feel connected to my clients through this new medium, but I do admittedly still struggle to feel comfortable with the process. I have faith that I will become more accustomed to conducting therapy online and it may even allow me to further expand my business once this frightening situation is over.

In the transition to online therapy, I have had to figure out a practical location to conduct my sessions. Walking to my office in the mornings with only dog walkers as my companions reminded me that I should probably not be leaving my home. That meant I would need to run my practice from home, where I live with my wife and three growing teenagers. Finding a room where the Wi-Fi was stable enough for a session proved surprisingly difficult and led me to try sessions in my wife’s upstairs office, my bedroom, and then finally my basement. I started out wearing nicer shirts during my sessions (while still wearing sweatpants) but have primarily let go of this pretense and now just wear clothes I find comfortable. Navigating the different online formats for sessions has forced me to become comfortable with Skype, Zoom, and therapy by phone.

Managing my own fluctuating emotions during this uncertain period has also been a struggle. Each morning brings new closures, growing red infection circles inching towards my province, and further suffocating restrictions on how we can live our lives (“Kids can go outside but don’t touch anything or play with anyone!”). I have needed to prioritize my self-care to feel grounded. Exercise, journaling, baths, mediation, practicing guitar, and reaching out to friends and family have helped me get through the days. Depending on how long this situation lasts, I may even finish the book I have been avoiding writing.

In the last few days, I have seen glimmers of hope. Slowly, my regular clients have been returning, giving me a deep sense of comfort when I survey my filling calendar. I am also acclimating to online therapy and can see some advantages (sweatpants). I still very much fear for the health of my family, friends, and society at large, both in terms of the health consequences but also for the lost jobs and economic stress. I take comfort in the idea that we are a resilient species, supremely adaptable and capable of overcoming enormous challenges when we work towards a common challenge. We will get through this; perhaps more aware of the gifts of good health, our loved ones, and our shared reliance on one another.
 

The worldwide events of recent weeks have affected everyone, and one of the most affected populations is our children. Young people often receive the “trickle down” effect of fear because of the reactions of adults around them to national and world events. The fear generated by this current crisis is magnified by the rapid change due to disruptions in daily lives. School, church, synagogue and play-space closings, and cancellations of team sports and organizational meetings hit people, and particularly children, on a deeply personal level. For children who get a lot of their sense of safety by watching the reactions of adults around them, seeing angry and fearful adults is unsettling, to say the least. As a play therapist, I see the need for play now, more than ever, to help our young people develop coping skills and express their fears.

“We Can Still Have Fun”

Last week I met with 9 year-old Steven, who was very worried about everything going on. His mother had called prior to the appointment to make sure our office was still open, and expressed relief that it was. As he entered the office he exclaimed, “At least something in this world is normal! We can still have fun!” For the next 55 minutes, he captured robbers, protected a city from the “evil stuff,” and built towers “where nothing bad could get the people inside.” For this little person, play was a way to make order out of chaos and feel safe. He kept saying to himself, “Everything is going to be okay.”

Playing Outside the Box

Telehealth has made it possible for the delivery of psychotherapy services to continue during this time of quarantine and office closings. Play can still be used in the telehealth format, although it may look a little different. Because I’ve worked with many kids over the years with autoimmune issues and other illnesses that make them home-bound, I’ve used play in telehealth with some modifications. Puppets, stuffed animals, or LEGO minifigures are great to use to tell stories, and building materials and mediums like Play-Doh and clay work well. As the child builds, the therapist reflects content and meaning as technology breaks down the barriers of distance. Often, just hearing the familiar voice of the therapist and seeing our face brings a sense of connectedness and comfort. Many of the telehealth platforms allow screen sharing where the child and therapist can share drawings and pictures, and some will even allow drawing together on a virtual white board.

Journey to the Unknown

Sebastian, age 10, has worried about viruses for a long time. Born with an autoimmune disorder, he has spent a lot of time in hospitals and doctor’s offices. He is no stranger to being homebound, and he remarks to me during an online session that this pandemic is much like a “journey to the unknown.” During our telehealth session, Sebastian made a spaceship out of LEGOs and told the story of a group of brave explorers who must leave their planet because it is dying. “It is not going to be easy,” he remarks, zooming the ship around in front of the camera. “We are journeying into the unknown.” Using the dynamics of our online setup, Sebastian suggested that I play the role of “Mission Command.” “You’re stuck back on the dying planet and I’ll be the guys on the ship.” Back and forth we went, with me commenting on the importance of the mission and bravery of the explorers, while Sebastian played out repeated scenes of danger and overcoming challenges.

Welcome to My World

Stephanie, age 8, has a vast stuffed animal collection. During a telehealth play session, Stephanie introduced me to several of her favorite stuffed animals. As our session progressed, she made a hospital “for the ones that got sick.” “Oh no, there are some sick ones; good thing there is a place for them to get better,” I responded. “Yes, I really hope that some of them don’t…you know…get really sick,” she said, making a coughing sound with a fuzzy elephant. “You’re worried about the ones that get really sick,” I reflected. After a moment, her face brightened. “Even if they, you know…die, the doctor has a way to make them alive again.” Despite distance and connected only through a screen, play was still able to give Stephanie a way to play out troubling feelings during stressful times.

Help for Families

Play is a powerful tool during this time when many families are homebound. Parents can use play to build deeper connections with their children and allow the child to express emotions and work through internal conflicts. Play can be a space of safety, bonding and communication. Helping the parents of kids we work with see the usefulness of play can also help the parents feel as though they are helping their children during this dark time. I tell many parents that one of the most important parts of playing with their kids is simply “creating space” for the play to happen. Usually, the kids take it from there.
While this time of crisis is certainly taking a toll on all of us, let us remember our children, and how play never stops being a bridge to better coping and making sense of a chaotic world.
 

For new therapists and even experienced veterans, the first session with a new client creates that anxiety buzz in your gut. You feel pressure to do a good job, to "hook" the client, and that pressure is real. Studies show that most folks wind up going to therapy only one time. Is there pressure? Yeah.

But making that first session work, regardless of your clinical orientation, is about salesmanship. Like it not, you need to sell yourself – your personality, your approach – to the client. If you do a lousy job, the client won't be coming back. Here are some tips for closing the deal:

1. Understand their goals.

If you've ever bought a car or refrigerator, you know that the first thing that a good salesman asks you is what you are looking for. Price range, size, manual or stick, side freezer or a bottom one? She then knows what she has to offer, what to zero in on.

The same is true for therapists: What's the problem the client wants fixed? Some clients do a better job of defining their needs than others, but your job is to drill down and get a clear understanding of what the client wants to get out therapy: improve communication in their marriage, reduce their anxiety, know how to help their tantruming child. If you both are on the same page about the goal, you're most likely to work towards accomplishing it and perhaps to reach it. If it's vague or the clinician veers off track for their own reasons, it's too easy to wind up where the client didn't want to be.

2. Understand their expectations.

Clients have some vision of what the therapy process is going to be like. You are going to ask about their childhoods and help them unravel them; you are going to teach them anxiety-reduction skills, you are going to be like Dr. Phil and let them know in 20 minutes what they need to do most. If clients have been in therapy before, ask about that experience, ask why they decided not to go back to that therapist. This gives you instant information about what they didn't like, did like, what you need to do differently.

And if they have not been in therapy before, this is a good time to explain your orientation and how you do therapy – that you are psychodynamic and you explain what this means, that you are a bit like Dr. Phil and behavioral and give homework. This is like the salesman showing you what she has to offer.

3. Stay in lockstep.

One of the things a good salesman does is stay in lockstep with you along the way. She shows you a car that is a bit over your budget but explains that it gets good gas mileage so that you'll quickly make up the price difference in gas savings. Or this refrigerator has a bottom rather than side freezer but explains how you'll be able to easily fit that Thanksgiving turkey inside it. And then she waits to see what you do next: You say you can't afford the extra car cost, that you never would need to freeze a turkey, or you say little but grimace. Depending on your reaction she adjusts – shows you the car in your price range, goes back to the side freezer. What she is doing is staying in lockstep with you. She wants to get solid yesses all along the way towards the close.

You want to do the same. You mention that you do a 3-session evaluation and make sure the client nods his head. You make an interpretation and you see if it hits home and resonated with the client or whether she makes a face or looks confused. Like the salesman, you want to stay in lockstep with your client throughout the session.

4. Watch the clock, control the process.

Unlike the car salesman, you have limited time, and to use that time effectively you want to watch the clock in order to control the process. Here you don't let Henry rant about his wife for 20 minutes, because that leaves you with too little time to hear his partner's side of the story and for you to mop up. Similarly, you don't want to run the clock up the middle of your evaluation questions and have no time for your summary, pitch and feedback.

Here it's helpful to think of the first session in thirds: First third, opening – rapport building, client story; second third, your assessment – what you need to know to confirm your hypothesis; last third, closing – your summary, client feedback, next steps.

5. Make your pitch.

This is about bringing together Parts 1 & 2 – the client's goals and expectations with your own gathered information. Here you provide a summary, you educate them about your approach to anxiety, you provide a preliminary diagnosis and outline of your treatment plan. Think of what your family doctor does after she does after her physical assessment. You do the same, and if the client has been in lockstep with you all along the way, you'll hopefully get a green light to go ahead.

6. Handle objections.

Or not. Your family doctor suggests seeing a specialist and you ask why. The car shopper test drives the car but then says he'll think about it. You lay out your treatment plan and the client says she isn't sure about her schedule or needs to think about it and will get back to you.

It's okay if clients have reservations or objections, but leave time to answer them. Regardless of what they may say, always respond with "That's fine" but then ask if there is anything else they need to know. You are looking to find the problem under the objection and counter with information.

7. Define next steps.

Provide a preview: I'd like to split the next couple session and see you both individually; here's some homework I'd like you to try; I think it would be helpful if you brought your son in with you next time. By laying out next steps, you build momentum and reduce anxiety by letting clients know what to expect and by showing leadership.

Undoubtedly you have your style, your own format for first sessions, but the key to successful first sessions is about avoiding a cookie-cutter-one-size-fits-all, going-on-autopilot approach. Think about what works for you, what doesn't. What do you need to tweak in terms of time management, your assessment, your pitch, so that clients not only have a clear impression of you and your approach but also leave feeling better when they walk out than when they walked in, believing that you're the right person for the right job?

***
 

So, have I successfully sold you on the idea that therapy is in some ways like selling? That an effective therapist must master not only therapy, but saleswomanship? Have I pitched too hard? Not hard enough? In either event, I hope that I have given you something to think about. Now, what will it be – the side-by-side or freezer-on-the-bottom? The 2-door or 4-door? CBT or, perhaps, something a bit less directive?

When fellow therapists learn that my entire practice is online, I usually get a look of surprise, followed by the question, "But doesn't that take away from the work?" I'm happy to report the answer to that is a big "Nope." Providing virtual support during an event like the COVID-19 pandemic has been an effective way to both help clients during times of heightened anxiety and stress as well as to continue to work. If you're questioning if now the time is to go virtual for this or another reason, chances are you're ready.

Transitioning to virtual support has been made easy by those who have come before us in the remote therapy world, and we now have a straightforward check-list to use when preparing. The main question I get from clinicians is how to make the process feel positive, supportive, caring and individualized for clients. Here are some useful ways that I have found to make the transition reflective of the great work you already do in your office.

Continue building your therapeutic alliance

• Don't apologize for the transition. This is not a loss for your client, this is a wonderful opportunity for people to remain connected and continue with the work during a time that might otherwise feel quite stressful and alienating for your client.
• A beautiful way to frame this is by expressing your continued dedication to your client by offering comfortable, safe, ongoing, individualized care through the transition to a virtual session. You can do this in session or in an email, making room for any type of response the client may have.
• Don't make this a big deal. It doesn’t have to be and may reflect your uncertainty more than that of your clients.
• Allow time in the session before transition for any questions your client may have.
• Create a written safety plan you can share with clients that includes any changes necessary if the session is not happening in your office. For example, if a client needs hospitalization and you would normally do this from your office, outline a different way to support this circumstance from their home.

Make the Most of Your "Home visit"

• Generally, your client will be taking your session somewhere in their home. This is a powerful opportunity for you to experience some of what you talk about in session in real time with your client. For example, a client struggling with insomnia and difficulty with nighttime anxiety may have listened when you suggested a mindfulness or restorative yoga practice in session, but what does that actually look like in your client's room?
• Use the client's comfort in their own home to practice different skills that may be less achievable in an office. If you use any guided mindfulness, meditation, or somatic techniques in your work, allowing the client to find the space that feels comfortable for them and to use their own pillows, blankets, and any objects of comfort to help can be really wonderful.
• Pets! In-home therapy animals. My clients respond well to having their cat or dog pop in and out of session, or even curl up on their lap when talking about particularly difficult topics. One of my clients even has an iguana who has made some surprise appearances – an in-home co-therapist of sorts.
• Be open to anything your client may want to share about their home environment. This is a great way to learn more about who you've been working with.

Make the Tech Comfortable

• Create a clear, organized email that has all necessary instructions for your client to access services, including links to the HIPAA compliant video platform of your choice. Bullet points are your friend here. Practice first by logging on to the platform as if you were your own client – include instructions based on your experience. Helpful information includes: Does the client need to provide any demographic info? Can they access the video platform on their phones, or just their computer? Do they need to download anything first?
• Have a video platform backup. Frequently tech doesn't work the way we intend. Have two video platforms available so that you can switch if needed. Provide this information to the client in the email you send.
• Plan for your first virtual session to start 5 minutes early. It might take the client some time to get things sorted on their device and it really helps to have this time built in, so the session doesn't feel rushed.
• Add a section to your consent form around teletherapy that your client can sign electronically. Again, this is straightforward and doesn't need to be anxiety-provoking. You can even purchase paperwork for this from private practice consulting groups.

Get Creative

Expanding the ways we are able to connect with clients also opens the door for innovative ways to engage in our work. Experiment with a shared online journal, have your client securely email you an art therapy exercise, try having a session in which your client can be by an open window, or even outside in a safe and private space by a patio or balcony if the weather is good.

The Case of Jane

For many of my clients, a virtual connection allows them to express emotions more readily. For example, Jane came to therapy seeking support around a relationship she found to be unsatisfying in ways she had difficulty articulating. I sensed that there was something Jane wanted to share and was very aware of my efforts to provide safety, so that she felt comfortable doing so. It wasn’t until she was alone in her home during a video session, sitting comfortably on her couch, that Jane was able to share some of her feelings around her sexual identity that she had never expressed before. She later remarked that the ability to experience therapy in the safety of her own space allowed her to access a part of herself that she had been struggling with acknowledging.

***

Overall, transitioning to virtual support has had little impact on my work. In fact, being able to provide safe continuity of care during such a challenging time has enhanced what I have been able to do with my clients.
 

I walked into the grocery store Sunday morning after a relaxing run. As soon as I came in the doors, I saw the headline of the newspaper in bold letters reporting that New York was in a state of emergency. Anxiety coursed through me. Earlier that same morning, I’d had a phone session with a patient who was becoming increasingly anxious due to news of the spread of COVID-19. She was starting to feel like she couldn’t leave the house.

New York City has been empty, comparably speaking. In a somewhat eerily quiet Midtown — where the crowd can make brisk walking a challenge — on Tuesday afternoon, I couldn’t help but be reminded of the days following 9/11, where in place of the vitality and determination that usually fills the streets of Manhattan, there was tense anticipation, like a cloud hanging over the city, just waiting for rain to pour down. And in both cases, no one had an umbrella to protect them, not even psychotherapists.

We are the ones who are to be containing anxieties, speaking to people about their fears, the trauma, not feeling protected. We’re supposed to comfort and soothe and help people use whatever resources they have to cope.

I have worked with trauma patients ranging from rape to incest to emotional abuse to people suffering after 9/11. I’ve worked in the prison system with perpetrators who were also victims. I’ve listened to stories that were utterly terrifying, heartbreaking, even some so bad they seemed unbelievable. Most of us know these stories and most of us know how to listen and allow difficult emotions into the room. We know how to contain them, which helps patients feel comforted.

A supervisee many years ago, working with her first incest survivor, asked me how she could empathize with something that was so foreign to her. I suspected that the content made her uncomfortable. Stories of incest can be very painful to hear and it’s natural that we have feelings about them whether we know the experience personally or not. Empathy, we had discussed, comes not necessarily from identifying with circumstances, but more so from relating, understanding and being with the patient in the difficult emotions associated with the traumatic experience.

We’ve all left sessions and been deeply affected by patients’ stories, their emotions, their experiences. But most of the time, we can separate their distress from our own personal lives.

But how do we as clinicians do this when we are immersed in the same traumatic environment?

Trauma is anything that fractures our sense of safety. What if our sense of safety is also compromised? When we are also inundated with information that traumatizes us, how do we help others?

It is important to be informed and updated, but the way the information about COVID-19 is being presented on some media outlets, and the amount of it, is creating an environment of hysteria, one we need to be able to step out of in order to provide effective care.
People are more likely to be pinned to the news when they feel unsafe, because it gives the illusion of control over an unsafe environment. But at the same time, the flood of news causes more trauma; so, the reaction to feeling traumatized is to look for comfort by reading information that’s being presented in a way that is more traumatizing. It’s so insidious, most people don’t even realize what’s happening to them or that there are things they can do to minimize the emotional impact.

In this way, it is a type of micro-trauma — small, subtle, consistent tears that break down our psychological resilience and resources, causing depression and anxiety, as well as psychosomatic symptoms.

So, what do we do to help?

The hard truth is that we were never safe to begin with. Our environment is always precarious. Of course, worldwide devastating events make us more aware of this, but it’s always there to some degree: anything can happen and everything can change — in an instant. I think as clinicians most of us know this. Most of us have found ways to accept this reality and to cope with it. Under normal everyday circumstances, the use of some denial is adaptive.

I find myself returning to this truth as I try my best not to be caught in the frantic energy naturally evoked when a state of emergency or pandemic is being announced everywhere and news that’s meant to inform the public is terrifying people. The headlines that capture attention, like NEW YORK IS IN A STATE OF EMERGENCY, are traumatizing people.

Reputable sources post their information more quietly. If you go to the CDC website, the information is written in calm, clear language, and is not meant to alarm people or cause hysteria. It’s meant to inform.

What we can do is to help people see where they do have control. The CDC advises us to practice good hygiene, to wash our hands, cover our mouths when we sneeze or cough with a tissue, practice social distance, be vigilant. These are things we can do. These are ways that we DO have control. Worrying is not going to change anything. But we can change our behavior in a way that is helpful.

When there is a global trauma such as this, our powerlessness over circumstances is highlighted to such a degree that healthy denial breaks down. We must help our patients focus more on areas they can control. Show them that they do have power over some things. There are things they can do. We must contain and redirect.

Additionally, we will be more equipped, emotionally, to handle whatever is presented by our patients if we decrease the amount of time we spend consumed by information that’s just making us feel more helpless. Being aware that too much news is a maladaptive attempt to cope with an unsafe environment is part of our role as mental health professionals. We so often talk about self-care being important. In this case, not drowning in news is part of this practice. We can’t change what’s happening, but we can adjust how we respond so that we can help others do the same.