Author: Psychotherapy.net Team

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.
 

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.