Is it possible to do psychotherapy effectively under lockdown? How should it be different from psychotherapy under normal circumstances? Are telephone/video therapy sessions good enough? How should therapists respond to client’s anxieties when they themselves are experiencing fear and insecurity? Is it okay to de-catastrophise patients’ anxieties related to the pandemic? Should therapists behave like national leaders during wartime, inwardly insecure and frightened but outwardly courageous and boosting public (client) morale? Should they be more authentic in the therapy room or hide away their emotions behind the therapist opacity and impenetrability that they can use legitimately.
During this crisis situations the emotions therapy clients are confronted with, are not very different from the ones they normally experience and bring to the therapy session, it’s just that instead of discussing their past emotional traumas and fears (ghost emotions) they are discussing their current anxieties (real emotions). Their habitual ways of reacting to them are also no different from the ones employed before i.e. being more frightened and feeling more insecure and helpless. What can be different here for the therapist is that they can’t approach the therapy material in the same way, as these are not imagined fears or a replay of old emotions that have no real consequences, and won’t endanger clients’ lives. A therapist’s reassuring stance can’t be justified here, as the disease can kill people and a denial of the threat can be dangerous. The therapist can’t assume – that these are mere thoughts and not the reality of the patient, which happens often in therapy.
The therapist can’t say things to mean – it was your reality before and your emotions were justified then but not anymore, you were scared because you were a little girl but not anymore, you were subject to traumatic experiences but now you can understand them differently and act in a mature way. The threat is real here and we need a different set of coping strategies – cognitive restructuring is not going to reduce the realistic fears, as it is supposed to bring people closer to the reality and not move them away from it. The CBT model is very good with unrealistic fears and cognitive errors.
Even if one attempted this it won’t work. As the saying goes – no amount of cognitive therapy can make me believe that the colour of the sky or the sea does not appear blue. The famous Sigmund Freud quote that therapy is about converting clinical suffering into normal human suffering, and it has no solutions for normal human suffering needs some reflection here. Here we are dealing with normal human suffering. Therapy does deal with the irrational aspect of normal human suffering such as relationship issues, work related stress, coping with normal life stress, but it doesn’t work well with the rational aspects of the normal human suffering. How to handle the rational aspects of normal human suffering? It seems that psychiatrist, psychologists and psychotherapists are not well-equipped with the skills in dealing with such unhappiness. It belongs to the domains of philosophy and spirituality. Let us examine what happens during therapy under normal circumstances, it is the healthy, rational, conscious part of the mind of the client that, with the help of the rational observation of the therapist, is able to detoxify the toxins of the unrealistic fears and fantasies in the unconscious mind of the client. But how can the situation be helped when the conscious mind itself is toxic with the fears and other negative emotions, as it happens during psychotic episodes, dissociative states and borderline personality disorder?
The therapy work is severely compromised. What happens during crisis times such as Corona pandemic and the effects of the lockdown is that the healthy part of the mind of the patient as well as that of the therapist is also emotionally charged and is engaged in coping with real life challenges. The therapeutic alliance, which is defined as the non-neurotic and non-transferential relational component established between patient and therapist is also under threat. Greenson (1965) defines the working alliance as a reality-based collaboration between patient and therapist. This reality based collaboration also gets impacted upon by the fears and difficulties of various kinds.
The therapy work therefore shifts from transference/therapeutic alliance to a different kind of therapeutic alliance during such crisis, where the client, with the help of the therapist, is working on their realistic fears as opposed to their illness linked fears. One might argue that the two are not totally independent entities, as the disease linked fears latche onto the realistic fears and make them worse. It’s therefore perfectly okay for the client as well as the therapist to spend the entire therapy session talking about client’s fears and thoughts about the corona infection and lockdown issues. The yardstick of measuring improvement would be that the patient feels less frightened of catching the illness and feels more empowered in dealing with their lockdown issues, and at the same time is not undermining the importance of taking all the precautions. They feel empowered in their ability to make a difference in the level of risks to their health, finances, relationships etc through their actions.
The importance of this work should not be underestimated as the skills acquired in dealing with one’s corona fears can be utilised by the patient at a later stage in dealing with their unrealistic unconscious illness-linked fears as well, and also the real life challenges. I was having a chat with my doctor relatives who were doing duties in corona infection wards in India, and I said to them, although it may be a nerve wrecking experience for you but if you are able to keep some equanimity (emotionally non-reacting attitude) during your shifts you will come out a stronger person. And after encountering these fears you will notice that your capacity to deal with fears of any other kind later in life will increase.
The therapy work will be possible only when the therapist is also able to put behind their fears and operates from the part of their mind that is fearless. The therapist should not undertake a therapy session if they find themselves unable to shake off their anxieties related to the infection and the lockdown, as they will only be passing their own psychological virus to the patient. It would be okay for therapist to acknowledge patients’ fears and discuss them but it may not be appropriate for them to discuss their own fears of corona infection and worries about the consequences of lockdown, as it may compound their client’s worries.
However, an existential therapist may have a different take on this thought, and may say being authentic will help the therapist work together with the client by being with them. On the practical front in my opinion telephone therapy sessions fall short of the requirements for therapy, but video sessions are good enough. Sadly many NHS trusts haven’t yet provided this facility to their therapists, although the costs involved are negligible compared to the good they will do not just during the corona crisis but afterwards as well. I am wondering what sort of psychotherapy will be helpful to the doctor, who comes to you as a client, who has just heard on the television that a hundred doctors have died in Italy as a result of the corona infection, and is now getting into his PPE gear to attend to patients in the corona ward. As therapists are we prepared to deal with such a situation apart from giving the client a patient ear to get the stuff out of their chest which gives the client a feeling that there is someone there to listen to them. It may help the client at some level as they know there is someone out there who understands their problems and feels in the same way as they do.
A CBT therapist might want to encourage their clients to reflect on the cognitive distortions of – black and white thinking, catastrophizing, overgeneralization, labelling, mental filtering (looking for the negative within every situation), jumping to conclusion (negative ones), emotional reasoning etc. There is a risk of irritating the patient as we are not acknowledging the patient’s real fears and minimising them. However, it may be more appropriate to use exploratory, experiential or phenomenological (existential) models where we give them a safe space and permission to talk about their thoughts of dying, financial ruins, job insecurities, relationship issues etc.
The client’s observing-self working in collaboration of the therapist’s unfrightened stance will offer a ground for detoxification of clients negative emotions. An acknowledgement of the suffering and giving them a safe space helps, but that isn’t enough to eliminate the suffering completely. For that one has to crate psychological immunity, like the military building defence capabilities in peace times. Crating a personality that has already come to terms with the ontological concerns such as death, uncertainties of life, loneliness, one’s thrown conditions, meaning in relationships, ultimate purpose of human life etc. And for that work to happen, as Freud rightly pointed out, psychotherapy is not fully equipped – one needs to look towards philosophy
©Kishore Chandiramani, Consultant Psychiatrist
Emotions Clinic, Education and Training Centre