A Therapy for Today: Telepsychology in the Coronavirus Age

When the world is stressed, people think of therapy. But what do you do if a therapist’s waiting room makes it impossible to maintain social distance or the office has closed?

Anxiety is understandable. The nation and the world are in self-isolation. We are lonely, apprehensive about our health, and worried about the well-being of our families. Don’t be ashamed of being scared amid this new but temporary situation.

The idea of psychotherapy intimidates many people even when coughs and sneezes aren’t more dangerous than usual. The only safe therapeutic option is now online. Not only is this a change for the vast majority of current patients, but daunting to contemplate for many coming to counseling for the first time.

Welcome to membership in the largest club ever, the unusual human condition of the day. To the good, the therapist wants you to tell him of any hesitations or worries about this unfamiliar, remote method of care. He will try to calm you and work within your limits. 

Even before you seek counseling, the following often helps:

Ask yourself what other challenges you’ve had in your life. Make a list. Remember the qualities inside of you that enabled you to endure and triumph. They are still present.

Here is information to consider if you are seeking live video treatment:

  • While telepsychology or teletherapy can include phone calls, this introduction is limited to simultaneous videoconferencing in real-time.
  • Imagine yourself sitting in front of your computer in a well-lit space. The therapist sees you above the waist, and you can see only as much of him. He hears you and vice versa.
  • Although there is a bit of a time-delay in the discussion, this is an as-it-happens experience, just as in a doctor’s office. Thus, appropriate dress is required. No pajamas! 
  • Some therapists are adept at providing counseling this way. Others are new to it due to our Coronavirus emergency moment. Ask the counselor about his experience with this medium when you reach out for an appointment.
  • The provider will talk about several more things before booking your first session. Among those topics are the following:
    1. You will need a computer that includes a webcam and audio for both talking and listening. He may ask for a few more details of your setup. A phone nearby is essential; headphones are helpful. This person will try to use words you understand if you aren’t computer savvy.
    2. He needs to be acquainted with your reason for calling him. A clinical psychologist considers whether he possesses the skills to treat you for the condition you describe.
    3. Questions related to your physical and emotional history should be anticipated, as well.

Further steps follow once an appointment is made:

    1. The therapist will send you a Telehealth Informed Consent Form and go over it with you. This will include potential benefits and risks of treatment.
    2. Payment arrangements will be made. Be assured that Medicare has agreed to pay for telehealth sessions during this emergency.
    3. If you are not covered by Medicare, check with your own insurance company to determine reimbursement for such services and what portion of the fee is your responsibility.
    4. The counselor will ask you to sign a release/permission allowing him to speak with an individual designated by you in an emergency.

The professional who treats you needs the competence to provide teletherapy. Technical expertise is necessary to address an unexpected failure of the audio or video connection. Ask about this.

FaceTime and Skype are not secure platforms for the delivery of videotherapy, meaning your protected health information in a session might be compromised and your confidentiality breached. Nonetheless, during the Coronavirus emergency, HHS (the US Department of Health and Human Services) is permitting the use of insecure platforms to meet the demand for psychological assistance.

The doctor will discuss potential privacy concerns within your residence. Will anyone try to hear what you are talking about? Might another person enter the room? Will a pet or child show up?

White noise machines may reduce the chance someone else will overhear you. You will be encouraged to minimize distractions to the extent possible.

Your telephone is used as a backup in case of temporary loss of video or audio, not as the primary source of communication.

Visual cues such as your facial expressions, tears in your eyes, or tremulousness in your movements are indications of your emotional state. He must know that you are not engaging in harmful activities within his sight, etc. None of these indicators are knowable if he speaks with you on the phone.

Research suggests that teletherapy patients are about as satisfied as those who participate in traditional office visits. Most dissatisfactions come from technical problems in the course of the sessions.

Consider this an introduction to the treatment closest to an in-person office visit. You can expect other matters to be brought up, too.

Do not take what you have read here as a complete overview of the field. As the virus peril continues, federal and state laws may well change rules to adapt to changing circumstances. These might impact the delivery of psychological assistance.

Know that help is available to respond to the heightened stress of our situation. Talented psychologists, psychiatric social workers, psychiatrists, and other license counselors will continue to render the comfort they provide every day.

All these health professionals work with you, not on you. If you embrace the idea of partnership, both of you will work to create a bridge to a better time for everyone.

—–

The photos above come courtesy of Laura Hedien, a gifted and generous photographer. They are Crossing Chicago River at Michigan Avenue on March 21, 2020, and Crazy Luminescence. Much more of her work can be found at: https://laura-hedien.pixels.com/

Coping with “Skin Hunger” in the Coronavirus Age: Entry from an Unwritten Journal

I’ve never written in a journal, despite offering the idea to many patients. Today I write because writing permits expression in the absence of nearness. At this moment, we mustn’t be close to others no matter what we want.

Yet we are the same creatures evolved to be social, to touch and more than touch: to shake hands, hug, embrace, caress, kiss, fondle, and lose ourselves in love and friendship.

We suffer from a pandemic side-effect called Skin Hunger by some, a too familiar, but unspoken condition among us, soon to be known by almost everyone. We have become experimental subjects in an unplanned scientific inquiry.

Still, today offered some small compensation. Here is a morning snapshot without mourning.

I wanted fresh orange juice. I’m lucky in many ways, including a meer 10-minute drive to a store that almost gives it away and a car to get there.

To minimize risk, I arrived early. Really early for those of you who aren’t seniors: at the high-risk age of our world’s coronavirus stage.

I entered at nine-minutes before dawn, a trip on night’s black edge: 6:20 AM.

Few people beat me in. The magic of automatic doors saved me from contact. Then a young woman employee walked by.

“Excuse me. Where are hamburger buns?

If we have them, they’re in aisle four.

I guess “if we have them” has turned into a reflexive response. Shortages because of the terror. I went to get the juice, whose location I knew, then to aisle four. Tons of buns.

One of the automated checkouts was in use, three empty. I completed the errand while maintaining social distance. Mission accomplished! We take our triumphs where we can find them within the constraints of our present moment.

Breakfast. I had a drink of water, then prepared my typical fiber-filled repast: shredded wheat manufactured without sugar, salt, and taste. With bananas today, though I often add blueberries if the price is reasonable.

Then coffee to feel alive. Most seniors require gallons, plus medications. I don’t take many of the latter, but the standard is relative. Friends report back problems and hernias from lifting all the pharmaceuticals they use!

Now for the major event of the day. Ta-da! Walking outside. Almost three miles.

People are friendlier but maintain distance. Almost everyone now waves or says hello, even from across the street.

An outlier on a bike, a woman, widened the footage between us from 15 to 25 feet.

Some folks walked dogs. Physical contact with a loving mammal. Think about it.

I passed modest homes and a few places an old friend compared to the Palace of Versailles. He was exaggerating, of course.

I got to thinking about how COVID-19 might alter our values. We take much for granted: life, health, work, restaurants, etc.

Perhaps, for a while, the condition of our being will be differently admired, differently evaluated, differently appreciated.

The status of simple things is getting a boost, decency among them.

The birds were out and a concert in progress. A legendary symphony conductor, Carlo Maria Giulini, told me he thought this the most beautiful music of all. No disagreement from me. Even the woodpecker with his built-in jackhammer joined the sing-along.

Some folks I know are stunned at the avalanche of bad news. The ones in feathered flight don’t care. Birds chirp, chatter, and sing in their first show of the day. We hear mostly males at that time, hoping to win a female heart and trying to mark their territory.

The scale of their satisfaction is smaller than ours.

Perhaps they offer something worth learning.

The Upside: How to Survive Psychologically in a Challenging Moment

I cannot say I’d choose to witness the Coronavirus pandemic, but here I am, and so are you. What follows is some help in reducing your distress.

I shall not minimize the dangers, but no good comes of either dismissing them or worrying over them as one would a train wreck sure to happen. The situation is neither.

If you are keeping up with public health recommendations, you know this. If you are taking the advised hand-washing precautions, you know this. Moreover, various branches of government in the USA are beginning to reinforce the societal safety net for those who need such assistance.

More action will come, though increased disease is inevitable for a while.

Assuming you are maintaining your social distance, you’ve taken a significant step. But what do you do with a less structured day now, time that used to be organized by meeting friends, going to restaurants or bars, and working in an office rather than your residence?

When our minds are left to themselves, they often travel to dark places. Here are a few suggestions to help you stay in the light:

  • Notice the changes in your life and the lives of others, without catastrophizing. The present is a remarkable time to be observing the world’s reaction to the virus. Be curious, watching and listening instead of evaluating and judging. Meditation may help with this.
  • Many of us have said, “Gee, I wish I had more time.” Now some of us do. What did you mean when you spoke those words? What dreams do you hold you now can begin to fulfill?
  • Reach out to people by phone, email, and social media.
  • Remind yourself of the things for which you are grateful. Daily.
  • Plan your activities for the next day before bedtime. Give yourself a sense of control and accomplishment. Focus on the doable without excess ambition.
  • Do not watch the news or political commentary at every moment.
  • Exercise, if possible in the morning light, to reduce anxiety and improve sleep.
  • Learn something new. The internet is full of educational possibilities, many without any cost. Perhaps something as simple as learning how to tie a Windsor knot:

 

  • Remember that if you are socially isolated, the prescription of interpersonal separation gives you much company, even if you don’t see those comrades on the street. We’ve been offered an opportunity to make ourselves interesting for ourselves and to ourselves.
  • If you lament the lack of a robust dating life, you needn’t apologize. Many more people are alone because of the dangers of visiting their usual haunts and loved ones.
  • If you are going through hell, keep going. Don’t stop until you find the path out.
  • Religious faith is sustaining at such times. Prayer and reliance on a higher power can be helpful.
  • People are fighting for you in the healthcare system, many also in government. Efforts are being made to ramp up diagnostic testing. Laws are being passed to make the tests free. Legislation providing paid sick leave from work is also in process, though not everyone is yet included in the plan. Watch the brief video below. The outcome is positive.
  • Much political activism is occurring online. I do not mean arguing with people. Engage in making the world better from your home to support your desire to improve the country.
  • The challenge of living in the time of COVID-19 is a chance to develop a new depth of psychological resilience. The Stoic philosophers believed we discover who we are only when we are taxed.
  • Make a list of the difficult situations you’ve survived. What strengths within you enabled you to do so? Tap such qualities once again.
  • Clean out your abode. Donate or dump all those belongings you no longer need.
  • Far more distractions are available than ever before in world history. Use them.

This crisis, too, will pass.

 

—–

The top image is called Sunset Dancer by Hurriagusto07. It was sourced from Wikimedia Commons.

The Danger of Secrets in Marital and Family Therapy

The watchword of therapy is confidentiality. Treatment success relies on the client’s trust. But, is it wise for mental health professionals to put themselves in a situation where keeping one person’s confidence can be used against others in the room?

Imagine the following. A couple comes to marriage counseling. They have a young daughter.*

Among the concerns expressed by the pair is the woman’s father, the child’s grandfather. He has accused his son-in-law of sexually abusing the little girl.

The woman tells the therapist her dad is unreliable, prone to irrational and outrageous statements. Moreover, he holds a long-standing grudge against the person she married.

The woman dismisses the idea of abuse by her mate, supporting his denial.

Several challenging weeks into the process, the man notifies the doctor he can’t attend the next meeting. He adds that it will be fine if his spouse comes for a solo session. She wants to.

On this occasion, she utters something never said to anyone: her father molested her when she was young. Indeed, her daughter is never permitted to be alone with the grandad for this reason.

Nonetheless, she doesn’t want the husband to know. The specialist affirms his intention to keep the confession secret.

The marital sessions remain on a downward trajectory, leading to separation and a divorce filing. The estranged woman now thinks her partner did touch the daughter inappropriately, consistent with her dad’s contention. Her earlier dismissal of this possibility, she claims, was part of an attempt to save the relationship.

Adding to the dilemma, the mother now aims for sole custody of the six-year-old. She also reminds the psychologist of his promise not to discuss or report the historical violation by her father. Legal action will follow if he breaches her trust, she threatens.

In hindsight, should the counselor have agreed to the individual appointment with the wife?

The doctor is in a box. If he reveals the mother’s history of molestation by the little girl’s gramps, she will bring suit. If he does not uncover this fact, his lack of reporting what he knows permits the woman’s demonization of her spouse to appear more convincing than it otherwise would.

The law, depending on the state in question, might yet offer a remedy.

In the event the therapist’s records of the unaccompanied session are subpoenaed by the husband’s attorney, a judge might overrule the wife’s desire to maintain the information as privileged and, therefore, outside of consideration by the court in a trial.

Nonetheless, this is a cautionary tale for all marriage and family counselors. A somewhat similar problem can occur in the absence of the child custody issue.

Within couples therapy, one party might tell the therapist of an ongoing extramarital affair in an unaccompanied interview. A different conundrum would be created thereby.

If the psychotherapist informs the naive partner of the infidelity, he has breached the confidence of the adulterer. If he continues the therapy, he is violating his responsibility only to provide care if he believes it can be potentially useful.

More examples might be offered.

An unseasoned health professional can find himself in a predicament with both ethical and clinical implications

Precise guidance to prevent such difficulties is not commonly found in the ethical guidelines of the various helping professions.

Therapists, one hopes, obtain enough supervision in the practicalities of their work to avoid horror stories of the kind described above.

Most of us achieve a measure of wisdom with hard experience and training. Of course, the truth of such a statement applies to much more than what happens in the clinic.

——-

*This essay is based in part on “Legal and Ethical Issues for Mental Health Professionals: Revised 2020″ by Psychotherapy.net Academy.”

The second image is Der wilde Mann (the wild man) by Paul Klee.

The Therapist as a Secret Keeper

 

If Zora Neale Hurston is right, the “oldest human longing (is) self-revelation.But to whom should we show ourselves? How much is safe to disclose? When? At what risk?

We’ve all thought of this, but perhaps not of the costs and responsibilities of the one who listens to the secret.

I’ll try to address both the teller and the Secret Keeper.

The act of unveiling is fraught. We believe the uncovered one is alone in taking a chance. She gambles with her psychological nakedness.

Will she be mocked, rejected, used? Will her confidence be shared with others, publicized? Will the knowledge that comes to the listener/observer be turned against her? Will her vulnerability be exploited?

Priests hear confessions, therapists too: the speakers are ashamed or tentative. Their confidences are like objects packed with care, wrapped in cellophane, new and easily damaged. They’ve often never been opened.

To the client, they seem tarnished, in need of cleansing, but impossible to free of stain.

The disclosures must be understood as a gift. Here is the most delicate and fragile beauty the individual owns, no matter how ugly he believes it.

The “oldest human longing” takes the form of “admitting,” out loud.Admitting” as in a ticket to enter and a statement of guilt. The terror in the treatment room bursts the confines of a confessional space because here, unlike in church, the listener also sees you.

Your face is known.

Though priests in the confessional want to know everything, counselors should be hesitant. To the extent they control the conversation, timing is critical. A too-early disclosure might cause the patient to flee therapy, overwhelmed by the early exposure, his armor melted.

Whether in or out of psychotherapy, most of us share parts of our lives. The external elements include appearance, words, and actions: the public portion of ourselves. Though this evidence of our person carries dangers (as when we make formal presentations), it is commonly without oversized hazards.

Not so our “off the record” existence. Think of the whole of your history, personality, and behavior as individual pieces of a mosaic, like a stained glass window. All the excellence and perfections, flaws and cracks: the light and the dark.

Some parts are shared with some people, but often not enough for them to imagine the assembled multicolored glass. The therapist, however, comes to know the entirety of it or can conjure a perceptive, imagined awareness of the nondisclosed portions.

He should ask himself a question. Does he want to possess the most sensitive, private, anguished knowledge of you? What is the cost to him of keeping safe what he hears? He, too, is at risk. A different kind.

The more the psychologist knows of untold stories, shames and “weaknesses,” hurts and horrors, the more he might be perceived as an indispensable and unique person to the client.

The giver’s sense of debt for his acceptance of the gift and the tenderness with which the counselor treats it, the bigger the challenge and responsibility. Some think of the Secret Keeper almost as a being out of fiction, one who holds the divulgence in his soul.

For therapists, this can be too much for the small enclosure in which it is contained. If he cannot help to disentangle the patient’s transference toward him, his overlarge hopes and expectations, growth and eventual termination become difficult.

If the sufferer does not come to take risks and confide in others, the pedestal on which the healer finds himself is too high for his client’s benefit and for his own long term occupation.

Most of those in psychotherapy detach without a long lingering empty space which the practitioner used to occupy. The aura of absence shrinks as the patient’s world widens. If the therapist was skilled and his patient courageous, growth and awareness of new possibilities lead to unveilings and disclosures outside the clinic.

The analyst is a guide and an expert, but his job is temporary. Enhanced flourishing gained through treatment doesn’t smooth all the roads ahead.

At its best, the patient becomes a better driver over and around those potholes and a more resilient survivor of the worst of them. He seeks places and people new to him, free of the claustrophobia of his head. Reward and compatibility with others encourage the continuing adventure.

The encounters with new people and their acceptance of him might call up thoughts of the counselor, the one who first saw and valued what he disclosed.

Now, however, there is a larger, freer world elsewhere.

_______

The second image is The Whisper by Charles Blackman, sourced from Wikiarts.org/ The final object is Whispering Zephyr by Thomas Ball, sourced from the Art Institute of Chicago.

In Search of a Rescuer: Where Erotic Transference and Politics Intersect

Most of us have hoped, early or late in life, for someone to “make it better.” Children want this when they fall. They need to believe instant magic is possible, and often it is. A smile, a hug, or a kiss can be enough. We are social creatures looking for connection, sensual and emotional.

When illness is serious, medical professionals are asked for their form of hocus pocus. Those people possess specialized knowledge. The name for it is “health care.” A proper physician communicates his expertise, but the care, as well.

Those with injuries to the soul seek a specific category of treatment: psychotherapy. You might be the perfect physical being, beautiful and whole except for the unseen pain of twisting emotion and turbulent thought. But, you ask, how much can another human do when no surgery or potion fixes what isn’t working?

Should the attempt to help succeed, admiration for the one who helped tends to follow. Sometimes before aid occurs.

The idea of a protector is potent and easily sexualized. “Someone to Watch Over Me,” the old Gershwin song goes. There are moments in life when we call out for such a knight or sorceress to summon the daylight.

The problem, though, is that life’s manufacture of dilemmas doesn’t stop. The factory assembly line can be unkind. Joys and sorrows are randomly generated. Nor does love offer a permanent cure-all.

The nourishment given by passionate and abiding affection helps with many problems, within limits. The lover (or potential partner) can offer only one hand when you find yourself in the soup of struggle. The other he needs to keep himself afloat. Lasting sorcery available 24/7 is in short supply.

If the therapy client searches for a deliverer or a romance in the counselor’s office, desire gets in the way of the best the therapist can provide: for the patient to rescue himself with expert and sensitive help.

The doctor’s assistance does not demand his becoming a brawny stretcher-bearer throughout the client’s life. Instead, the latter learns to take on present challenges and get past his past to make his way.

To do so, our wounded hero must allow (in small doses) uncomfortable emotions access to his heart. Similarly, he begins to permit uneasy topics and memories admittance to his thoughts. Taking responsibility for recovery requires behavioral changes, too; actions he hesitates to try. New and more workable ideas will disentangle the ones binding him if he recognizes their mirage of false security and unties them.

Some argue there is a benign supernatural healer in an afterlife, but I don’t know anyone who claims he now walks the earth. Some of us do, however, mistake mortal beings for more than they are. Thus, no matter the gifts of the therapist, he is not, by himself, the answer.

Current politics reflects this problem. Close to half of the United States thinks they’ve found their savior, a sheep in wolf’s clothing. Nothing short of a no-holds-barred holy terror will save them, they believe.

The other 50% hopes a nobler protector is yet to come. The latter group has been disappointed in people with names like Mueller and fears there is no other metaphorical wolf-slayer at hand.

Here, as well, many who wait and dream make the same error as some counseling clients. The hoped-for wizard in the office is like the fictional Wizard of Oz, just another man. The heavy lifting of well-being will require the muscle of those who lift themselves. The psychologist might suggest a path and a pace, display encouragement and understanding, but no more.

Neither a passive role in counseling nor remaining inactive until election day will accomplish a rescue, whether it be from personal despair or a case of national turmoil.

In 1867 John Stuart Mill put the governmental situation this way:

Bad men need nothing more to compass their ends, than that good men should look on and do nothing.

It is often quoted in these words:

The only thing necessary for evil to triumph is for good men to do nothing.

Whether the worthy man or woman is a therapy patient or a nervous citizen in a shaky republic, he is tasked with principled action to effect the change he wants.

Postcard and letter writing, marching and registering voters, phone calls and donations wait for us only for a while. Energy enacted creates its own source of energy, confidence, hope, and a sense of control: steps in the defeat of passivity, dependency, and worry.

Walt Kelly’s old Pogo comic strip told us “We have met the enemy and he is us.”

If the cartoonist were working today he might prefer this, a remedy of which each of us should remind ourselves:

I have met my rescuer and I am he.

When You Feel Lost

I was warned.

I was warned about bad neighborhoods when I began to explore the world. Relatives portrayed it as an unkind place where bad karma, bad luck, and bad people lurked.

They seemed to mean they waited for me alone.

Parents ought to warn, but not so much as to form a fearful youngster. In time I took my chances and dared to explore.

Not only the city, but myself, the uncovering of my self: exposure to condemnation and humiliation, rejection, and all the common disgraces uncommonly hurtful when they happen to us.

How else, I reasoned, can I be known?

We need to get lost a few times to make our way. We must be disappointed in our fellow man to distinguish those worthy of trust from those who are not.

Our job is to fall down but not stay down. To enlighten ourselves not just from books, but the game, the ladder, and the heart.

Lewis Carroll wrote, “If you don’t know where you are going, any road will get you there.”

He advised us to make goals.

But isn’t taking unknown trails to uncharted destinations also an essential message?

How about “The Road Not Taken”?

Two roads diverged in a yellow wood,
And sorry I could not travel both
And be one traveler, long I stood
And looked down one as far as I could
To where it bent in the undergrowth;

Then took the other, as just as fair,
And having perhaps the better claim,
Because it was grassy and wanted wear;
Though as for that the passing there
Had worn them really about the same,

And both that morning equally lay
In leaves no step had trodden black.
Oh, I kept the first for another day!
Yet knowing how way leads on to way,
I doubted if I should ever come back.

I shall be telling this with a sigh
Somewhere ages and ages hence:
Two roads diverged in a wood, and I—
I took the one less traveled by,
And that has made all the difference.

Is the verse grim? The poet, Robert Frost, wished us to smile: “My poems … are all set to trip the reader head (first) into the boundless.”

If we take him by the two last words — “the boundless” — perhaps one meaning is to fill life with experiences, adventures, and explorations of the world without and the world within.

Might we reveal to ourselves who we are by searching the unfamiliar places, the avoided challenges, the prospects we fear? How else shall we overcome them and recognize our flourishing resides in growing mastery?

Perhaps misdirection and disorientation lead to unexpected joy.

The admonition “know thyself” cannot be fulfilled without discovering our choices in unaccustomed circumstances, with people different from ourselves, attempting skills not yet expert.

Until we are swept away and carried aloft how can we know where to land?

Enlargement of life comes from living it, unless you enjoy confinement.

Possibility awaits outside the box, outside the lines, outside. Beauty, too.

When I was a boy, I recall older kids saying “get lost” to those young ones they didn’t want nearby. They meant, “stay away.”

But might a wise mentor say to a young man, “lose your way,” as a strange kind of guidance?

Every so often, “getting lost” might be just the thing. Early enough, when time is on your side, before dark.

Until you trod the unpaved, unplumbed, unfamiliar off ramps a few times, you won’t ever discover your hidden resilience.

Perhaps only by getting lost on occasion can we find ourselves.

——-

The first image is Lost Bird Logo by Tánh Nguyễn. Next comes Arnold Böcklin’s Isle of the Dead in its 1883 version, followed by Blossoming by Paul Klee. All are sourced from Wikimedia Commons.