- Heather B MacIntosh PhD
Therapy in the time of Covid-19: A few thoughts and some recommendations for therapists
Updated: Jun 8, 2020
Social media has been inundated with pictures of people finding creative ways of connecting, human-to-human, in the real world, in this time of physical distancing and covid-19 precautions. Photos of grandparents standing outside a window peering in at a new grandchild, grandchildren showing eager grandparents art creations and notes of love through the window of a nursing home, masked families performing drive by birthday parties for their distanced beloveds, have warmed our hearts in the midst of this lonely, scary time. These acts of creativity speak to the essential nature of our embodiment and the irreplaceable relational role that in person contact plays in our connections with others. Really, making a zoom call to grandma would be much easier than arranging a trip to the nursing home for a drive by window visit. The lengths to which we will go to be in proximity to those we love dramatically demonstrates the power of physical contact.
What then does this mean for psychotherapy, where the human-to-human relationship is already constrained by what is called the “frame”, the room in which the two or more people meet, at a prescribed time, for a prescribed amount of time, for a prescribed fee? What does this physical distancing mean for both patient and therapist and their relationship?
That moment of reaching across the divide, handing a Kleenex, or two, or three, a moment of meeting, the tissue links us as we come to know one another in the creation of a new relationship and a safe place for diving deep into unhealed pains and traumas. There is always a box sitting just to the left and yet, in that first moment of spilled over tears, the box, invisible in the blur of vulnerability, opens the door for our joining in the simple act of reaching across the space between us to share a tissue. Such a simple act, now impossible in the time of covid and virtual therapy. I now watch, helpless, as the tears of my patients flow into shirtsleeves and balled up fists, and roll down unprepared faces; it is as though it is my job to supply the tissues and, without me, they must suffer in the absence of us both.
Many, perhaps even most, approaches to psychotherapy do not involve physical touch. In fact, the majority of psychotherapy models eschew physical touch due to the potential for violations of the boundaries and abuses of people who come to us for help and healing in their most vulnerable moments. As a psychologist who specializes in trauma, I need to be especially mindful of the harms that have been committed against my patients by those they should have been able to trust to protect them and hold their safety in the highest esteem. So, physical touch is usually limited to a handshake upon first meeting and, when requested by the patient, a hug at “graduation”, which could be six months or sixteen years later. Between the brackets of this minimal touch, our physical bodies do not come into direct contact. And yet, we are, in every moment, engaged with one another, body, mind, and spirit, as we work towards the common goal of healing horrors embedded in minds and bodies.
As a singer, I have spent my life breathing in tandem with others. The regulation of breathing in and breathing out, the sharing of respiratory focus brings us into a state of mindful focus on the same goal of creating beautiful music. Those of us who have lived lives of singing in community know, in our bones, the benefits to our wellbeing of singing with others. There is a vast body of research that has documented the benefits of singing in groups including enhanced immune and cardiovascular functioning, improved mood and social connectivity as well as reductions in mental health distress including symptoms of anxiety and trauma (MacIntosh et al 2020).
What does this have to do with psychotherapy? Well, it is obvious that we are breathing together when we are singing together but, it less obvious that we are breathing together in the consulting room. At times, we are breathing in tandem as we await the emergence of a thought, a feeling, a word; the something that is waiting to be birthed in the space created for diving deep into healing. At times, we are breathing in tandem as a shared process of working together to reduce levels of sympathetic nervous system hyperarousal triggered by the exploration of traumatic memories and feelings as we inhale and exhale together, consciously, to settle and regulate in the face of emerging horrors. At times, we are breathing in tandem as an unconscious co-regulatory process of sharing the rhythm of call and response as patient and therapist engage in the back and forth of the archaeological dig that is psychotherapy.
All of these ways of breathing together do not happen, automatically, on zoom or skype, doxy or veesee. We lose the gentle non-verbal rhythm of shared breathing when we are living our relationships over the internet. We can, sometimes, hear the other’s breath but we are also living in time lags, and working with information about the body of the other based on, essentially, a recording of what is happening in that other person in that other room across town or across the country. We lose the unconscious co-regulation that simply occurs as we entrain our breathing with another. We lose the settling impact of scaffolding our dysregulated nervous systems as we relive and reorganize painful experiences and traumas in relation to the regulated and regulating therapist who is holding themselves on emotional dry land as we traverse the dungeons and dragons of the past.
And so, like those who struggle to read social cues and need them translated into rules and explicit language, the move to online therapy requires explicit and intentional efforts to find our way into shared experiences of breathing and co-regulation. Even with a time lag, I can monitor the breathing of my patient, I can consciously engage in entraining to their respiratory rhythms insofar as that is possible with the technology. As we go deeper into darker places, I can be explicit in the importance of continuing to breathe together by counting for us both as we breathe in and out to an externally dictated rhythm. It is not the same as the gentle, unconscious shared breathing of in person connecting but it is a way of being committed to shared regulation even though it is less automatic and perhaps feels less natural.
Seeing One Another
In the world of online therapy we can see one another but our seeing is radically changed—what we see, what we can see and how our minds and brains experience that “seeing”. No longer can we look into one another’s eyes, comfortably avert our gaze, count the tiles on the ceiling of the therapist’s office, bashfully find one another as the battle to quell the shame imbued by traumas and painful experiences that wound our ability to be with one another safely and closely. In essence, it is me looking at a picture of you looking at a picture of me, writ large! All of a sudden not only do we see the other as a large colour picture of a torso on a screen, we are also thrust into the awkwardness of staring at ourselves on the screen, larger than life.
The words and the music of therapy are equally important. With zoom and Skype and other technologies, we get to keep the words but the music is inexorably changed. No longer do we see all of each other’s bodies, experience the textures and smells and sensations of being in one another’s physical presence, and most of the non-verbal subtleties, the bread and butter of much effective therapy, are lost. And, this is further complicated by the stress and strain on our mental, emotional and nervous system functioning by being thrust into a visual space that defies all of our evolutionary training about how to be with and experience and understand one another in our shared humanity.
Mirror Neurons and our Social-Relational Evolution
Part of how we understand each other and experience empathy is through activity in the brain about which we are completely unaware. One of the important mechanisms for understanding one another and experiencing empathy is through the action of what are called mirror neurons. Mirror neurons do exactly as you might imagine, they mirror, these neurons fire together; when they fire in one person, they fire in the other, essentially simultaneously. These neurons evolved as a part of our social-relational survival system as they fire when our caregivers smile and, eventually, we smile. Over time, this becomes a complex system of social-relational functioning and connection. In essence, mirror neurons are how we, neurally, experience and understand emotions in others. I am a singer so I’m not sure if other people have this experience but, when I am enthralled by a singer performing a song that is challenging and exciting, I find myself breathing with them, I notice my throat and vocal chords are moving ever so slightly, I find my torso tightening in a long phrase, in essence, my body is going along for the ride as though I were singing, myself. A similar thing happens in psychotherapy, we find ourselves holding our breath, feeling feelings that emerge from the other, unconsciously “getting” something without needing all of the words that might explain that something. In a review of studies about mirror neurons and their nature and functions, Kilner & Lemon, (2013) noted that proximity is important; the closer the observer is to the person performing a task, the higher the number of mirror neurons that fire and the greater the level of social learning. Additionally, and more to my point, when a monkey observed a researcher performing a task through live observation versus over a video stream, the percentage of mirror neurons that fired was almost double to that of the video feed observation. Those of us who have spent many, many, hours on zoom over these past couple of months would likely concur that we are missing something and that something is hard to describe.
The Brain has two “Selves”
Another way in which the world of online therapy is missing out on lived experience is in the limitations in the activation of our right brain, sensing and perceiving, and how vital this is to our understanding and connecting with others. The brain is divided into two hemispheres, the right and the left. The left hemisphere is the side of the brain that does all of the talking and is generally where verbal language is processed. The left side of our brain tends to think it’s the part that reflects, knows and understands the things that are happening around and within us. However, the right side of the brain is the side of the brain that catches all of the non-verbal, sensory, and embodied signals that come from around us, and that part of the brain works way faster than the left side of the brain…so, while you think you are coming to understand or know something using your impressive language and deductive reasoning skills, in actual fact, your right hemisphere probably got there first and fed you all sorts of information you aren’t even aware of having received. Alan Schore, a prolific writer about the psychotherapy process would suggest that most of what happens in therapy happens in the right hemisphere. In fact, in his book, The Science of the Art of Psychotherapy (2012) he argues that what popular culture and the field of psychoanalysis have come to understand as the unconscious is really just the activity and action of the right hemisphere. He further suggests that much of the communication within the psychotherapy process and relationship happens through what he calls, right brain to right brain communication. Anyone who has spent much time in psychotherapy, on either side of the couch, will be able to tell you that there are things that come to be felt, known and understood that are never spoken aloud and that these are often the most powerful aspects of the work. How then, can this vital aspect of the therapeutic endeavour be experienced in the absence of physical presence, live eye contact, and access to the non-verbal cues that feed the right hemispheric “knowing”, when we are sitting in our little square zoom box?
Where to put the Bodies?
One of my favourite things to notice is how bodies and pillows and postures change over the course of therapy, especially with couples. I am a psychologist who works with a lot of couples, mostly couples who are dealing with the impacts of traumas experienced both within and outside of their current relationship. With in-person couple sessions, couples come in and speak volumes with where they sit and how they sit in relation to their partner. These opening moves in the dance of couple therapy tell us about how hurt, frightened, estranged, and angry couples might be. Often couples gravitate to the farthest reaches of the couch, as far away from one another as they can get, sometimes erecting Berlinesque walls out of the throw pillows and Kleenex boxes. With video therapy sessions, couples are robbed of this simple way of helping me see how they are feeling about their partner and regulating their proximity to help them manage feelings of vulnerability of overwhelming hurt and pain. Trust me, there is nothing so anxiety provoking for a couple therapist as a couple in high and escalating conflict sitting in one another’s laps trying to fit into the scope of the video camera!
The term zoom fatigue has entered common parlance. It refers to the mental and physical exhaustion experienced by those of us whose work has moved online and in-person activities have been replaced by video conferencing. Those who have started researching this phenomenon point to a number of factors including needing to use more energy to stay focused, the greater challenges in processing non-verbal cues like facial expressions, the loss of rhythm between silence and speech, where silences evoke anxiety rather than rest, and, of course, many of us feel very aware of being seen in a different way-a feeling of being unable to hide; we can’t escape seeing ourselves on the monitor saying and doing and being. Essentially, a highly complex interpersonal system that integrates visual, language, non-verbal and body cues has been reduced down to explicit language and the limited visual cues we get from a video call.
In addition to the simple experience of shifting our engagements to online formats, all of a sudden we no longer have any of the diversity and activity of our pre-covid lives. For many of us, we do not get out of our chairs and go out to the waiting room to greet a waiting patient or walk across campus to go to a meeting and pick up a quick coffee on the way; our lives have collapsed onto that one comfortable chair in that one corner of the office where our work lives exist, in totality.
My patients have told me that, similarly, they miss the routine and rhythm of leaving home and going somewhere to go to therapy, the ritual of giving space, time and location to the work of healing that is separate and apart from “normal” life time. They have described a kind of-it’s better than not but—feeling. They talk about feeling anxious about privacy if the parent or partner about whom they are talking is lurking outside the door, listening for the whispers of betrayal. We miss each other. We miss the moments of meeting that can only happen in the impossible to explain moments of being, being together, being in proximity, breathing-smelling-feeling-humanness. In some ways, this time has reinforced the pain of that which we only rarely speak, how the therapeutic relationship is and always will be a caring creation that exists outside of the possibility of looking through the window at a new grandchild. Part of how therapy can be so healing is that it is protected from the sturm und drang of daily life and relationships and, yet, this is also part of why it can feel painful; covid times have accentuated this divide.
What To Do??
It has taken me two weeks to write this blog post, mostly because I, like all of us, am struggling with the fatigue and concentration difficulties that have emerged in the midst of this pandemic. We are all dealing with a radical shift in the rhythms and routines of our lives while also taking in and processing the looming realities of how our world is changing and will be forever changed by this pandemic. So what are some things we therapists can do to stay well and keep finding ways to help our patients during this life changing experience?
Compassion. It is rare that an experience is so universal, our patients, our own therapists, our students, and all of the people of our lives, are experiencing this global, frightening phenomenon. So, go gently, with yourself, your people, your patients. In the midst of your own fear, remember that we are all in the same boat—well, many little different boats but, you see what I mean.
Supervision and Personal Therapy. We need to speak openly about this experience with our patients and, for some, that level of self disclosure feels uncomfortable or vulnerable; if it’s hard, reach out to your therapist or a supervisor you respect to help you navigate these new ways of being in relationships. Managing the new therapeutic frame and new ways of navigating the boundaries of therapy requires a lot of reflection; this is an ideal time to connect with a supervisor you trust. This pandemic may also be triggering emotional states and old traumas in such a way as the time is right to stay connected or reconnect with our personal therapists. We need to attend to those responses if we are to be fully present to our patients. I’ve never met a therapist I really respected who hasn’t spent a lot of time on both sides of the couch.
There are a number of online courses on the ethics and practice of online therapy. Many of these are free of charge. While being aware that it can feel like a real burden to add one more thing to the to do list, these are one way of feeling resourced and confident in this time of great change. I am a part of peer support group and this is invaluable to me in my work, especially when these kinds of challenges face us.
Be Explicit. As discussed above, the impacts of the shift to video sessions mean that things that might once have been communicated through non-verbal cues and the stimulation of right brain to right brain communication and those handy mirror neurons can not be assumed. We will not likely know what those things are until we find ourselves in a mess of misunderstanding and hurt. So…say everything out loud, be explicit, ask more questions, be more transparent, share more of your own feelings and thoughts, show up as much as you are able and notice when you are not.
Take Breaks. A young man I supervise was telling me the other day that he took the week off because he was finding it all just too exhausting. Now, the weird thing about all of this is, there is nowhere for him to “go” and, so, we might feel that taking time off doesn’t make sense since we will just be sitting in the same place anyway, however, we need to notice when we are no longer able to concentrate and be present and respond accordingly. Set your schedule up as though you are doing twice as much work as you think you are since your brain and your mind likely have different ideas about that. Take breaks between patients to get out for a walk or do some stretching. I have tried to move to having some no clinical days so that even if I am working on research, I can still have a larger proportion of the day where I am not on video calls.
Be Creative. For some therapists and patients, being on video conferencing for a full session can feel exhausting and over stimulating. For these patients you might shift to doing more frequent, shorter sessions. For couples, you might suggest that they actually sit on different devices in different rooms to allow them the space to regulate themselves. I work with some couples that actually sit in their separate vehicles to make the calls to me so that they have both privacy and room to regulate. Have more individual sessions than you might otherwise. I find that, especially with couples, the possibility for missing things, making errors in understanding, and leaving a partner out to dry, on zoom, is much higher than in in person sessions. Consequently, I am having much more frequent individual sessions to check in about how they are doing, how they are finding the therapy, how I may be missing them or leaving them feeling stranded in the therapy. I am also doing this because of the increased risk of conflict escalating into violence in the context of covid social isolation, I want to make sure that I am able to ask explicit questions about their conflict without risking anyone’s safety.
While it is still recommended that psychotherapy remain online as some healthcare sectors move towards reopening, there may soon be ways that we can start being creative about connecting with those of our patients who are particularly hard hit by the separations. Being mindful of confidentiality and privacy, my private practice is located on my farm so I am hoping to be able to soon start taking walks around the property with patients, keeping our six-foot distance and wearing masks. I am also in the process of repurposing a wood shed on my property into a new office as my existing office will never allow for physical distancing recommendations, especially with couples. Is there a way that you can protect the privacy and confidentiality of your patients and still spend some time in physical proximity, even if only for a short hello to look into one another’s eyes and reconnect one body to another?
I have been surprised that some of my patients prefer the video therapy. That is a whole conversation of its own but, we will likely see that when the recommendations of health authorities and professional organizations allow for resumption of in-person sessions, some of our patients will opt to continue with video sessions. While that will perhaps be the subject of another blog at another time, I believe that we need to learn how to become proficient at online therapy for it is here to stay, in one way or another.
This is an opportunity to explore this new way of doing therapy and being in relationship with our patients. Let’s rise to this challenge and, then, go, take a walk, and remember to breathe.
Kilner, J. M., & Lemon, R. N. (2013). What we know currently about mirror neurons. Current biology : CB, 23(23), R1057–R1062. https://doi.org/10.1016/j.cub.2013.10.051
MacIntosh, Heather B., Tetrault, Amanda, Vallée, Jean-Sebastien. (2020). “trying to sing through the tears” Choral Music and Childhood Trauma: Results of a Pilot Study. The Journal of Choral Music Research.
Schore, Allan, (2012). The Science of the Art of Psychotherapy. Norton.