Author: Psychotherapy.net Team

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.
 

As a therapist in private practice, along with having five years’ experience as a bereavement coordinator in hospice, I can attest to the complexities around end-of-life caregiving, both for the family and the professional.

Whether the loved one is at home or in a skilled setting, the burden of care can be overwhelming. Regular folks are suddenly confronted with medical decision-making, legal considerations, financial questions, not to mention the actual day-to-day interaction with the loved one who is dying. To add to that, the caregiver will likely have a job, family and other obligations.

When they are overwhelmed by the physical and emotional toll of their responsibilities, caregivers often show signs of anticipatory grief: anger at the exhaustion, frustration at the never-ending demands, shame for wishing it were all over already, helplessness at not being sure what they should be doing and sadness at the way time is running out.

How do we begin to work with these clients?

Making Sense, Making Ritual

As an existentialist, my focus is around making sense of that which is unknowable. I find one of the most effective ways to help caregivers to find meaning during this time is to uncover significant joys, rituals and mementos. I have found that singing the songs of youth, making meals that bring back memories, or even sitting together watching birds to be ways caregivers with whom I have worked are able to connect with their loved one at the end of life, and that can help them move towards a place of acceptance after the death.

During the last weeks of my dad’s life, we read through a well-loved book of bad and bawdy jokes from the vaudeville years. Even when he could no longer understand the meaning, he would laugh at the inflections of his daughters’ voices, his muscle memory recalling something deeper. Years later, I keep that book.

Once death has taken place, the transitional period during which the loved one shifts from physical to spiritual presence is an important phase of healing¹. Rituals have been used effectively for years in religious and cultural ceremonies and by therapists who understand that creating unique ways to honor the departed aids the grieving process. So, recognizing the unique characteristics of the individual while they are living and highlighting these attributes and delights can help to make this transition easier for the caregiver following the loved one’s death.

For intuitive clinicians, this is a fantastic opportunity to think outside the box with the client. Tattoos, animal totems, reimagined articles of clothing, and connection through natural elements are frequently utilized by clients with whom I have worked, but it doesn’t need to stop there.

One client struggled with letting her father go until we created a ritual around visiting their favorite golf course, where she buried some of his golf balls. Unorthodox to be sure, but it helped her immensely.

Dealing with Dementia

The cruelty of dementia has no bounds; robbing the family of a loved one inch by inch before the body has time to react. It is a harsh twist of nature, and it can be very helpful to recommend a support group for those struggling to come to terms with this very personal and unjust theft.

When counseling a caregiver whose loved one’s deterioration is both painful and frustrating, I have found it important to help them to acknowledge that they are no longer dealing with the lucid and logical person they once knew. This is often the hardest part for these caregivers: accepting that logic is no longer accessible, nor is the person that they love and who loved them. The caregiver cannot make them remember, change their newfound (mis)beliefs, help them reason or provide assurances that relieve their anxiety.

The caregiver’s role becomes one of simplifying, calming, redirecting and comforting. Many elderly with dementia understand in the beginning what is being lost, and the frustration and fear is obvious. The caregiver can be reminded to acknowledge the pain, recognize the magnitude of their loss and just be present.

Some form of suspicion or, at the extreme, paranoia, is frequent: Why did you take my car keys? Who's paying for this apartment? Why can't I have my checkbook? That isn't my signature on that document! Where am I? Where is my husband – what have you done with him? As heart-breaking as this can be, the caregiver needs to intentionally practice patience and calm in the face of the storm.

I have suggested to these clients that they join in the world that is real for their loved one; since they simply cannot tell reality from fanciful thinking, dreams or stories they've been told, asking them to recall what the loved one cannot recall often causes great embarrassment and frustration.

It may be helpful for caregivers and their loved ones to remember some tips for better communication:

• Memory may be better at certain times of the day; later in the afternoon, confusion may increase, a phase called "sundowning"
• Talk about broad topics, not specifics
• Phrase questions in a way that they don't feel anxious if they don't know the answer
• Don't correct or contradict their memories, even when they are wrong; just join them in their world
• Engage with touch, sight and body language
• The loved one may not be able to follow stories or movie plots; consider reading simple, shorter stories

 This kind of psychoeducation is important for those who are going through this lonely journey. As therapists, we must be able to validate and normalize with the client. Competency in serving clients – both family members or professionals – means knowing about the dying process and being able to walk alongside them during this transition. Being aware of the types of dementia and their different impacts on individuals can help bring understanding to bewildered caregivers.

While one elder was in the latter stages of Alzheimer’s she would continually try to “elope” (leave the secured facility without permission). Her daughter, in an effort to find humor in an otherwise dreadful situation, took to lovingly referring to her as “Houdini.”

Boundaries and Self-Care

Caregivers who are anticipating the demise of their loved one experience the full range of emotions, from sadness to guilt to rage. In my work with caregivers and their dying, I have found that no matter the dynamics of the relationship, guilt and self-recrimination are real. Most of these clients I serve replay the “If only I had…” mantra after the death; this has been the norm for me. The idea of having to balance self-care with the real needs of the dying is hard and there is no absolute.

In the course of my own clinical experience with these clients, the need to deal with caregiver burn-out is often great and it becomes critical to remind them that we cannot pour from an empty bucket – if they have nothing left to give, they cannot truly help. Recharging the batteries enables others outside of the immediate sphere of loss to relieve the caregiver or provide assistance. As counter-intuitive as this seems, asking for specific requests can provide a way for those in the life of the caregiver to be and feel useful rather than burdened and helpless. Suggesting the client make a list of chores or needed help can stave off burnout and help the client to maintain some sort of emotional and physical balance. Counselors should encourage reaching out whenever possible to support services such as neighbors, family, friends, religious or civic groups.

When my young cousin was dying of cancer, her parents and husband were with her every day. As the illness had impacted her speech, she was difficult to understand, so visiting could be anxiety-producing. Her lasting gift to her friends, however, was asking for certain foods – bringing her a smoothie, mashed potatoes, ice cream – made us all feel that we had contributed to her comfort.

Final Thoughts

Hospice work became a passion for me when I sat with my cousin in her final hours; I came to understand that there was a great honor and privilege in companioning the dying and their family members at the end of life. As I learned through that work and my own family’s losses, the medical community provides much care to the dying, but not so much support for the caregivers. I was inspired to write Take My Hand: The Caregiver’s Journey, after following blog posts by a friend caregiving for her mother. Her experiences underscored that caregiving can be the loneliest job and reaching out provides comfort.

The gifts I have gleaned from this soulful work have been a true blessing of sharing in moments of insight, joy and incredible grief. To hear the stories of youth and the weariness of decline has enabled me to experience the full scope of life.

References:
Wolfelt, A. (2015). The paradoxes of mourning: Healing your grief with three forgotten truths. Ft. Collins, CO: Companion Press.   

“Acceptance is such an irritating word! What the hell? One is supposed to ‘be okay’ with all the crap that happens?”

I am sitting with my patient who pounds his fist with frustration on his thigh. He works long hours, has a terrible commute, is a single parent, and to top it off, his autoimmune disorder is flaring up and his joints ache. He’s in the middle of a ferocious divorce. In the evenings he is exhausted. The sink is piled high with dishes. Instead of cooking, he orders takeout, which he and his kids eat in front of the TV. He feels terrible. He consoles himself with Instagram and ice cream. Too much ice cream. He’s gaining weight. He wants my help in changing this habit.

“I should be able to get the dishes done. I should be able to cook a meal for my kids! And I shouldn’t be eating like this!” He drops his head. “I can tell myself that I need to change my habits, but it won’t happen. I won’t do it.” He puts his hands over his face. “It shouldn’t be this hard.”

Acceptance means to be okay, even when things are really crappy. Not just to be okay, but to be okay with the crappiness. To lay aside that powerful word “should” and stop demanding ourselves, or the universe, to be different than we are. My patient and I both know in our heads that something positive lies in this direction, and we are both feeling rather mutinous about it. My resistance to acceptance has been that it implies approval, like getting accepted into college. It feels almost offensive to be asked to send a thick welcome envelope to some craptastic aspect of life.

But what if we ease into it? Might that not be a little easier? One dimension of acceptance is to see things clearly, accurately, as they are. We could make that a first step, and call it “acknowledgement.”

A dear mentor, George Haas, founder of Mettagroup in LA, turned me onto one of those wonderful Buddhist lists. This one breaks suffering into three categories:

Type 1: We grow old, get sick and die. The same is true for everyone we care about.
Type 2: We don’t get what we want, we have to put up with what we don’t want, and when we get what we want, it doesn’t last.
Type 3: The subtle, constant, ongoing irritation that nothing is exactly the way you want.

My patient is experiencing a solid dose of all three types of suffering. Oddly, when I share this with him, we both start to laugh.

“Right. I’ve got a chronic illness and I’m tired and in pain when I come home. I have a demanding job with a hard commute. I’m in the middle of a hellish divorce. And I always get to the end of the bowl of ice cream.”

He relaxes and starts to cry. After a bit, he wipes his tears.

“And I really, really like ice cream. I guess it’s kind of silly to say this shouldn’t be hard.”

Maybe we are ready for step 2: “appreciation.” Appreciation is defined as “full understanding, recognition of worth.” Nothing is perfectly good. Is it not also true that nothing is perfectly bad? Can he gain a more balanced awareness of his experience?

He starts to give it a try, and immediately wrinkles his nose. “Eww.”

I nod. “Mmm, yeah. Not quite there yet, huh?”

“No. My life looks pretty dingy compared to the glow of the better life I could be having.”

We just sit and breath together for a few moments. He leans forward.

“But I know that life is imaginary. And for all of its glory, that perfect life casts harsh and inescapable shadows. And compared to many people in the world, I have it pretty good.” He closes his eyes gently this time, reflecting on his life as it is.

“I’m tired, and this is hard. The reports at work that no one reads. The grim faces on BART [Bay Area Rapid Transit]. My aching elbow and the way my skin feels rashy.” He takes another breath. “I got a seat on BART today.” Another pause. “I listened to a podcast about megalodon sharks. My middle daughter will get a kick out of that. I really, really love my kids. If I didn’t feel tired, I’d probably be trying to get them to do something ‘educational’ instead of just hanging out with them. We are having fun watching Star Trek together.”

He looks up at me, and smiles.

“Maybe I’ll improve my habits. I hear dark chocolate is pretty tasty. And I could get a plastic bin for the sink so at least the crap on the dishes can soak while I’m not doing them. I can be okay with that.”
 

On January 11, China announced its first death from the Coronavirus. On January 13, the WHO reported a case in Thailand, the first outside of China, and Japan's health ministry reported a confirmed case. The WHO said later on January 23 that the outbreak did not yet constitute a public emergency of international concern and there was no evidence of the virus spreading outside of China.

I was concerned enough to bring face masks and antiseptic wipes in case people were coughing on the plane, but on January 24, my husband and I boarded a plane to Sydney, Australia. A couple of people were wearing masks on the flight, but not many. I didn’t put on a surgical mask, but I wiped my food tray and arm rests with the antiseptic wipes. While we were in Australia and New Zealand, we kept hearing that the virus was spreading.

When we returned from Sydney on February 26, the Japan Airlines lounge was not serving food; the staff in the lounge walked around spraying disinfectant; and the flight attendants all wore face masks. More than half the people on the flight were wearing masks as well. My anxiety about the virus increased exponentially.

On my first day back to my office, my first patient, Rosalind, asked me about my vacation and then turned to her anxiety about the Coronavirus. She said she had ordered a carton of Lysol and Clorox wipes; she took her shoes off and washed her hands upon entering her house. Her son had a doctor’s appointment at a hospital and she wasn’t sure if she should cancel it. She asked if I was scared because I’d just been on a plane returning from vacation. Since she has an anxiety disorder, I thought it was important to help her separate out her internal reality from the external reality, but it was not easy.

“I understand why you are concerned. There is a danger of the Coronavirus spreading and it makes sense to wash your hands frequently and use Clorox wipes. But I think it’s important to try to separate the reality of the virus and your internal anxiety.”

“Yes, that’s exactly what I need to do.”

“While it’s important,” I continued, “to wash your hands and use antiseptic wipes and try to avoid crowds, it is also true that most people who get the Coronavirus don’t die from it. Elderly people with underlying medical issues are the most vulnerable.”

“Yes, people with respiratory problems. Yes, I’m not elderly and in perfect health. Yes, that helps.” She took a deep breath.

After that session, I felt conflicted. On the one hand, I didn’t want to frighten my patients or subject them to my anxiety. But, on the other hand, I needed to protect myself as well as my patients. I walked around the office with a can of Lysol and sprayed all the door handles. But I needed to model a way of coping with a frightening reality that neither denied it nor exaggerated it. I decided to put Clorox wipes in the waiting room with a note saying: “Please wash your hands or use one of these before coming into the office.”

When Rosalind returned the next day, she remarked on the Clorox wipes and said it made her feel safer. She thanked me for doing it. I felt good about it; I felt I’d found the right balance between keeping the office safe and without unduly frightening my patients.

But then Florence came to her first appointment. She told me that while I was on vacation she had found out she had cancer! I was stunned. But she seemed calm about it so I strained to keep calm. She told me the story about what had led up to the diagnosis and then turned to another subject.

“I visited my mother in her nursing home over the weekend and it was fine. Everything seemed normal. My son Ronnie went on Sunday and spent 45 minutes there. It’s a good thing we went because on Monday morning, they started a ‘no visitors’ policy.” She laughed.

I felt a rush of anxiety. She visited a nursing home? I was frightened for her because she is in a compromised state, and also because she could now be spreading the virus!

I didn’t question her decision to visit her mother, and I didn’t point out that she put herself in a vulnerable position. But I felt anxiety running through me — for her, her son, and for me. As soon as she left, I walked around the office spraying Lysol on all the door handles.

So what is my conclusion? I do not have any answers, because dealing with the Coronavirus is a work in progress. We have to feel our way. I think I have to keep walking the fine line between keeping my office safe for my patients and myself and not letting my anxiety get the best of me. But as it spreads, patients may not want to use public transportation or they may get quarantined. I will offer phone sessions if either of those things happen. At times like these, it’s good to talk to our colleagues and commiserate about how to handle this crisis and others like it that we may encounter.