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.

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.

What Your Therapist Didn’t Tell You

Many therapists spend most of a session without uttering a sound. The more they talk, the less they are heard. The more they speak, the less the patient does his own emotional processing.

The more they offer answers, the less the client claims ownership of his happiness, responsibility, and control.

When treatment works, the seeker isn’t passive but active. The new thought is taken, not given. He grasps the reins, a voluntary effort.

Clinicians should rarely propel the train, though they may clear some of the tracks. Persuasion and insistence have limits. A parental, authoritative position creates a struggle for power or dependency.

Repetition is tiresome. Some people won’t change. They sought a remedy with the wish for someone else to do something.

We are not surgeons who administer an anesthetic so you can be redesigned while unconscious. If we possessed a storeroom full of magical potions, we’d be drinking them ourselves.

The counselor asks questions, points in a direction, and monitors the strength of the resistant wind. He manages the temperature and allows hope to enter the room.

Who will reach for it? Not all do.

Like marriages and friendships, there are signs of trouble. The sessions drag, the medic becomes a debater, misunderstandings occur. The analyst drains his life force; perhaps he dreads the next appointment. The psychologist tries too hard, his counterpart too little.

Though the lesson is unwanted, the other’s life is not ours to reshape. The patient has the right to stay where he is, no matter the suffering.

The only adult we can alter is the one in the mirror. The man reflected in the silvered glass must reflect, claim his own agency, and act.

Mallets won’t hammer others to the shape desired. We are not sculptors or portrait painters. Sometimes the best we can do for another person is to give up on our capacity to do him good.

At least this permits him to take back his life.

Some people, including a few “helping professionals,” listen to be heard, to make pronouncements. They do better to listen to understand.

We all have limits. We all have goals and choices. Regarding the latter pair, here are mine for 2020:

To better understand myself and others. To discover an enlightening idea, an unexpected sight or sound.

I choose to search for these; and perhaps to change the world.

The Risk of Emotional Openness: Of Therapists and Their Pedestals

Most of us in the West assume a stance of “openness” to a degree my parents and immigrant grandparents thought shameful and dangerous. Yet our casual ease in talking about “the personal” still has limits: lines not to be crossed.

On the dark side of that border, one finds all of us who are not “known.By this, I refer to the hidden aspects of who and what we are. In Notes from Underground, Dostoevsky wrote about the parts of ourselves kept below the earth:

In every man’s memories there are such things as he will reveal not to everyone, but perhaps only to friends. There are also such as he will reveal not even to friends, but only to himself, and that in secret. Then, finally, there are such as a man is afraid to reveal even to himself, and every decent man will have accumulated quite a few things of this sort.

I had a taste of my mother’s notion of the proper place of privacy in repeated statements like, “What would the neighbors think?Her family’s advice for what was and wasn’t discussed came from a generation whose education was Eastern European and specifically Jewish.

Amos Oz, the late Israeli novelist, born in 1939, offered this commentary on those who fled Europe for Palestine before the genocidal erasure of their families and friends by the Nazis:

They had no difficulty at all in expressing communal feelings — they were emotional people and they knew how to talk. (But) the moment they tried to give voice to a private feeling, what came out was something tense, dry, even frightened, the result of generation upon generation of repression and negation ... They could never be certain that they would not utter something ridiculous, and ridicule was something they lived in fear of. They were scared to death of it.

Here, perhaps, is a partial answer to why so many of our friendships and romances fail. We want to experience the freedom and comfort of another’s knowing approval, but hesitate to leave more than a trail of breadcrumbs leading to the secrets Doestoevsky mentions.

No signpost to our camouflaged essence directs the curious to know what we want to be known, but dread will be known. The ridicule that terrified Oz’s parents is thus avoided.

Obstructions to external acceptance of our innermost selves are still more numerous. Unlike those mentioned, these come from the deficits in the ones whose respect we crave.

Few potential friends and lovers know how to enter our protected internal spaces or realize they misunderstand us without so doing. Much work is involved in achieving a depth of awareness of another person, time thinking about more than how to win someone’s friendship, or get naked with them.

Our observers see only the surfaces we present. I’m speaking of qualities like our appearance, intellect, or quick wit. We blind people with our externals, intended or not. What is obvious is like the topsoil of a garden, suggesting little of what lies underneath.

Beneath the stereotype applied to their veneers, the beautiful and smart, the handsome and wealthy, are always harder for an observer to see as they wish to be seen.

As amateur analysts of the human condition, we imagine most compatible acquaintances offer no challenges to comprehension. They are thought to be like us in nature, philosophy, and motivation, with perhaps a few variations due to age, gender, race, nationality, and religion.

Not always.

Whatever uniqueness exists in their clandestine attitudes and behaviors often defies stereotypes. The more unique they are, the less likely they will fit our usual classification system.

One group is skillful in lifting the veils of those who might dance away from in-depth exposure of who they are: therapists. With enough talent and experience, they uncover much of the shrouded but exceptional humanity missed by so many.

This quiet recognition astonishes the ones who are now, perhaps for the first time, recognized. The power of the event and the wizardry often attributed to the counselor confers a significant part of the appreciation and, sometimes, the love directed toward him.

The healer’s discovery confers on him a weighty obligation, as well. While he treats many patients and might feel great affection for them, he does not (if playing by the rules) share the same extent of meaningful attachment to them that he receives from them.

Whenever any of us recognizes the inner-truth of an unknown, defended soul, we are placed on a metaphorical pedestal. How do we manage the esteemed position conferred upon us because of our x-ray vision into his heart?

How much care and carefulness, how much gentleness, ought to be given to someone who believes we (and only we) hold the secrets of his universe? 

Regardless of whether one is a therapist or not, we now receive a responsibility we did not seek, ownership of a particular station in the life of the one stripped of his mask. Therapists, close friends, parents, or lovers — almost all of us sometimes take on the weight of this — or walk away in disregard.

No simple directions exist for managing the unsought for status. Comments on therapy blogs make clear that the best mental health experts can leave an indelible imprint. The memory of them may long occupy a living space in the minds and hearts of former clients, not quite a first kiss but still on a high shelf of importance.

In such cases, counselors are inclined to believe they have done their job. While they opened the patient to possibilities, that openness comes with the sometimes painful knowledge that much of their future will be lived without visits to the individual who did the unmasking.

Helping professionals think the toll is worth the reward, but only the client can say this with certainty.

I’m convinced not all do.

We live in a world of love and loneliness. Most of us have experienced both. The impact of being known is extraordinary enough to change the life of the one so revealed and accepted — accepted despite revelation of the dark treasure within their confidential, invisible fortress.

Not everyone you meet risks traveling to this place. Not everyone locates somebody who might hold the key to their closeted existence. No wonder Vincent van Gogh wrote the following in a letter to his brother Theo:

Many a man has a bonfire in his heart and nobody comes to warm himself at it. The passers-by notice only a little smoke from the chimney and go their way ...

The stakes are considerable for the unseen. Their smoke signals disappear in a moment unless repeated. Even then, not all follow the vapor and welcome what they find there.

What else can the undiscovered one do? Will he speak the words and uncover his feelings before a stranger?

The risks echo. Is the hazardous path to “becoming known” a wise adventure or a dangerous one?

Perhaps both.

—–

All of the images above are the work of Mark Rothko. In order, Untitled, 1968; Untitled, (Light Over Grey), 1956; Untitled, (Light Cloud, Dark Cloud, 1957); No. 12, 1960; and No. 17 (Greens and Blue on Blue) 1957. I encourage you to take more than a few seconds to look at any one of these and discover what is beneath the surface impression, a visual analogue to the subject of this essay.