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Sunday 26 April 2020

Under Pressure

Diary of a therapist

What happens to people struggling with difficult problems in counselling when there is a global crisis affecting everyone – including the therapists?

Day 1

I am not sure how I’m feeling about all this… the “c word”. Are people going to want to talk about it? Is everyone already sick of talking about it? Do we need to talk about it? These were some of the thoughts which went through my head whilst disinfecting surfaces in my therapy room before starting a day of regular appointments.

Of course, everyone wanted to talk about it! There is so much confusion, disbelief, suspicion, panic and a noticeable increase in anxiety. Anxiety can often be experienced as physical symptoms, like chest pains or shortness of breath. These are also symptoms of the virus we are all being told to watch out for.

We revisited lots of grounding exercises and mindfulness exercises today. Simple breathing exercises, breathing in through nose, right into your stomach and releasing slowly; counting breaths, engaging senses of sight, hearing, touch, smell and taste. I need to remember to practise myself.

Day 2

So, is therapy “essential contact” when considering the latest social-distancing guidance? For some it is a lifeline. How can this be managed? Are the chairs in my therapy room far enough apart? I have read the guidance, but I don’t know where therapy fits. I have spoken to my supervisor and peers. No-one knows.

I have broached the possibility of moving to video sessions for the time being. There were mixed responses from clients. Some ignored, some changed the subject, some looked worried and some agreed. Every client, as the session ended, said: “I’ll see you next week.” I don’t think that they meant on their computer screen or phone. This face-to-face connection is important for people. I know from experience that online therapy is really effective but many people are suspicious of change and there is certainly a lot of that going on all around us right now.

Day 3

One long-term client talked at length about how it feels so safe in my therapy room. I offered a small scented tea light candle that I usually burn in sessions for them to take and use at home if we need to change to online sessions. I wondered why I did this. It brought to mind Winnicott’s theory of the “transitional object” (such as a teddy or comfort blanket) that a child uses to soothe when separated from their parent. This made me realise that we need to be doing some urgent work on self-soothing with all clients. I don’t have enough tea lights to go around.

Day 4

Working with couples can be challenging. Often, people come to couples’ counselling as a last resort, when the relationship is really in trouble. I never envisaged that I would have to work with couples in crisis whilst talking about how they might manage, what may be a very real possibility of them being quarantined together at home for a prolonged period of time.

I have worked with James and Emma for almost a year. We usually focus on improving their communication, some deep-rooted issues about their sexual relationship and their different views on starting a family. This is really emotional and painful work, but now we are back to basics, looking at how they can communicate that they are absolutely getting on each other’s nerves whilst both working from home. This is a couple who find it very difficult to ever raise an issue which may result in a disagreement. We might need to keep practising.

Day 5

How do we manage shared parenting in times of social distancing and isolation? It is painful sitting with Jo discussing the potential difficulties of children continuing to pass freely between two homes.

Jo and her partner have been separated for some time. They have two boys, aged seven and nine, who divide their time equally between their parents. This has not been without its difficulties, but it was just starting to settle down before this pandemic. Jo still found the time without the boys difficult and she is now terrified at the possibility of being separated from the children for a prolonged period of time if they fall ill whilst staying with their Dad. She told me that the boys have also started to worry about this.

Day 6

Keeping in touch with the various therapeutic communities on social media feels like a blessing and a curse. Everyone seems to have different ideas about what we should or shouldn’t be doing. I am noticing that I am in the minority in continuing to work with clients face to face. It feels as though I need to make a decision about this today. It isn’t a decision I want to make and would welcome some more direction from our government.

Day 7

Wow, this is fast-paced. I had not anticipated that we would already be at the stage where clients are losing jobs. This is difficult. I am also self-employed. How do I balance staying safe, providing support and paying my bills? More difficult decisions to make.

I am noticing that in so many different ways, people are facing messy, unplanned endings. Losing jobs, losing loved ones, finishing therapy, being forced into early retirement, unfinished school/college terms. The results of this could be so far-reaching.

Jo has lost her job in a restaurant and is now at home with the children. She has emailed to say that, for the time being, she will have to take a break from her sessions. This feels like an example of a messy ending. It is always difficult when work with clients ends abruptly. Therapists spend a lot of time in training learning to sit with “not knowing”. It is a test of this when work ends abruptly. Someone that you have built up a relationship with disappears and you don’t know how they are doing, you are curious about how their life is now and are unable to get answers. I suspect that the experience in sitting with “not knowing” is going to be useful in current times and something which clients are also going to have to learn to deal with.

Day 8

Today was difficult. I held my last face-to-face sessions with clients for the foreseeable future. This means more uncertainty at a time when people are feeling vulnerable. Some clients have already moved to video sessions and, although we’ve had some technical glitches, I think most were relieved that it was not as bad as they feared. The word which comes up again and again is connection. We all need to feel connected and I worry particularly for some of my elderly clients who were already feeling lonely and isolated.

This is in sharp contrast to the reminder I had in another couples session where they were clearly at war. I have only worked with Dave and Hannah for a few months. The sessions are often difficult as they struggle to learn to live together as a blended family.

Hannah was a single mum of two girls, both with additional needs. Dave, who has no children of his own, is struggling to adjust to his role as a stepfather.

Today, meeting them both via video call, the difficulties felt all the more intense as they were sitting close together on my computer screen, rather than in safely spaced chairs in my office. Hannah is particularly worried about how Dave will cope with the children if she were to fall ill. She has already been at home for a week, having experienced a sore throat and a temperature last week. She is currently feeling better, but now Dave (a teacher) will be working from home and the children are not at school. They are snappy and impatient with each other and I work with them to try to agree some household rules, boundaries and safe “time out” for all of them. This has made me think about the fact that, for some, home is not a safe space and how difficult this is going to be for them.

Day 9

First video session from home today. I have set up camp in my spare room. The cat seems to think he has to be with me at all times. I can see that he is going to try to introduce himself to the clients. I have lost almost half of my clients in 24 hours. Some do not want to work remotely, some have lost their jobs or are scared about their financial security. I have gone from 22 appointments booked for this forthcoming week to 14…

For the clients who remain we have had all sorts of struggles as people get to grips with using Zoom for the first time. I have had to think on my feet, with back-up phone calls, WhatsApp and FaceTime. I have been mindful of trying to remain calm when the technology doesn’t work, as the last thing the clients need to see is a panicked therapist on their screen.

Day 10

The initial sessions via video have been something of a novelty for some clients, but I have also been surprised at how intense the work can be. There is something about the closeness of the client on the screen and, as I can only see their face, I am finding I have to concentrate more than usual because so much is lost to me by not being able to read general body language, such as the tapping foot that might be saying, “I want to get out of here”.

I have had my own supervision by Zoom and found myself fascinated by trying to look at my supervisor’s home behind her. Therapists rarely disclose much about themselves to clients and this can lead to much curiosity and fantasy about what their personal lives may be like. We are now in a position where clients get a glimpse into my home (and of my noisy cat) and I am also getting to see a different part of their lives.

I am speaking to clients sitting on their beds, in their children’s bedrooms, their conservatories and in their cars. Another difference  (which I am not particularly enjoying) is getting used to seeing my face on the screen. I do not usually see my responses to clients in sessions and, now that I can, I am realising that my “poker face” is rubbish!

Day 11

Today, working with Jake, a client I had worked with for about eight months before moving to Zoom sessions, it was difficult to not be really affected by the emotion I saw on my screen.

When Jake initially came to see me in my therapy room, he had been signed off work with stress and had been unable to go out of his home for several months. During our work together over recent weeks, Jake had been able to leave his home, start a new job and travel on public transport. All of this had been impossible for him during the summer last year.

Having only recently returned to work, Jake was now once again back at home. “Trapped”, “scared I will go backwards”, “angry”…. There were lots of tears. These tears are also new, as Jake had previously not allowed himself to cry as it was “weak”. After working together for a while, Jake has begun to allow his feelings to show as they arise. I shared with him that I had also had a few “big cries” this week and that what he was feeling was perfectly normal in an abnormal situation.

Day 12

Today’s Zoom sessions provided some amusing moments. The first was when the call was repeatedly interrupted by static. The client was sitting surrounded by toys and told me that she was in her daughter’s bedroom, her partner having taken her daughter out for a walk to ensure that we had some privacy. The static turned out to be a walkie-talkie which was under the chair, with the children next door inviting us to go into the garden to talk to them over the fence. This provided us both with an opportunity to laugh after discussing her fears about the future of their family business.

Another client whom I have worked with for three years, Sue, when discussing whether she was fearful about her husband’s plumbing business being affected by current circumstances commented, “not at all, have you seen the crap people are throwing down their loos instead of toilet roll? He’s going to be busier than ever”.

Another client, calling me from his parked car by the dual carriageway, pointed out a lady walking down the dual carriageway in her pyjamas, with a Tesco’s bag.

Day 13

I have worked with Mary for two years. She is in her 80s and has recently moved out of the home she shared with her partner of 20 years into her own flat. We have been working over recent weeks to help Mary adjust to living on her own and building her “nest”. It was difficult today, hearing how lonely Mary felt, how she was fearful that she may have made the wrong choice and how she was now unable to finish furnishing her new home. We talked about how Mary can continue to feel connected and I suggested that she might want to speak to her children about whether she could call them on Skype and just watch the grandchildren playing for a while.

Day 14

Catching up with James and Emma, who are now both working from home. Emma is high-risk, due to health issues, and we spent almost a whole hour discussing whether James was really washing his hands for 20 seconds – Emma did not think that he was. It was important in that session to ensure that both of them had the same ideas about what safety and hygiene meant, and we discussed how they could deal with any disagreements that arose.

Day 15

I have worked with Mike for four years. He was diagnosed with terminal cancer four years ago and his prognosis was a year to 18 months. I agreed at our initial meeting to work with him for as long as he wished and have seen him each week since then.

Our work has often been difficult as Mike comes to terms with facing death and leaving his family behind. We had always discussed that, when his health deteriorated, I would visit him at home. Mike’s health has recently deteriorated, with the cancer spreading to his brain. He requires further treatment and is not certain whether he will be able to receive this. We are also now having to talk about the fact that, for the foreseeable future, the only contact we can have is via video link. This is tough! What I have noticed, however, is that Mike has been facing death for several years now and therefore is not as afraid as some of my other clients.

Day 16

I am noticing that most of my clients who had previously suffered with intense anxiety are actually coping better than many others. They have lived for months or years in a state of hyper-vigilance, they already experienced the world as a dangerous place and have skills in place to manage this. I am reminding them that they actually have an advantage over many in having skills to deal with the unknown, uncertain and terrifying. For some, they now have a focus for their anxiety, there is a real threat to their safety.

Anxiety is rarely a response to something happening right here, right now. It is usually about something that has happened or that may happen and often the client does not know the root cause of their anxious feelings.

One of my clients who was suffering from crippling panic attacks is enjoying the opportunity to be safe at home and has commented that she feels less panicky than she did before. She recognises now that she can manage her anxious feelings as they arise. In working with anxiety and panic, I often use a traffic light system. Green is when we can manage anything that arises, amber is our warning sign when things are starting to become difficult, and red is when we have tipped into feeling overwhelmed. I often work with clients in recognising their own amber behaviours and thoughts, and to act on them before they reach red. We never go directly from green to red. There are always stages in between that we can learn to try to manage.

Day 17

Another two clients down…. I think that the reality of the situation we find ourselves in is kicking in, and many are going into survival mode. In survival, we let go of things which are not essential for us to live. As finances become limited, people will prioritise food and paying their bills over continuing in therapy. One client, however, commented today, when we discussed her increasingly difficult financial situation, “my therapy (you) and Spotify will be the last things to go”. She also thanked me for the sense of “normality” which our weekly sessions continue to bring. I suppose that in a world where everything is uncertain right now, the certainty of meeting with someone at the same time each week can at least provide some sort of grounding.

Day 18

Today was my first experience of talking to someone about coronavirus conspiracy theories. I have worked with Maria for about three years, mainly in relation to relationship breakdown and anxiety issues. She is very straight-talking, often extremely blunt. We enjoy a shared sense of humour and I was surprised today to hear her talking about the virus “not being real”, “the government are hiding something”, “why are they trying to force us to stay inside”, “what aren’t they telling us?” “We need to look carefully to see what this is covering up”.

As a therapist it is often the case that we have differing views to our clients and this is something which I am used to holding back in my sessions as it is important to see things from the client’s perspective. I had to remind myself of this throughout the session and made a mental note that this was something which I would need to discuss when I next speak to my supervisor. I was also mindful that denial is a really effective coping mechanism in times of trauma, and my impression of Maria was that, although she was very angry, she actually seemed to be frightened underneath it all. As we finished the session, Maria commented that she was irritated that “keep safe” seems to be the new “goodbye”.

Day 19

I decided at the start of this pandemic that I would offer a number of sessions free of charge to frontline NHS workers as a small way of giving back. I have been working with a palliative care nurse for a few weeks now.

I have been thinking that many of us are reverting to our usual trauma responses of fight, flight, freeze, flop (I am struck by how this particular nurse is definitely in “fight” mode and keen to run towards the danger). She wants to return to the hospital wards to care for C-19 patients and is deaf to the concerns of her family about her doing so. I am in awe of her spirit and lack of fear and her drive to care for others, regardless of the potential dangers to herself. This is something I would want to explore with her once this crisis is over, if I get the opportunity.

The sessions are very difficult for me personally, as she talks openly and in a matter-of-fact way about Do Not Resuscitate orders and people who are dying of this virus suffering a “really terrible death”. Usually, at the beginning and end of each day, I would travel to and from my office, which is time to process my day. Working from home, I felt a real weight as I walked down the stairs at the end of our session with those words “really terrible death” going round and round my head… words I wish that I had never heard.

Day 20

There have been mixed responses today to the news that Boris Johnson has been taken into intensive care. One client, in particular, was really upset and said they had not slept at all the previous night after hearing the news.

The general mood was that this felt more serious, and there was some real fear that if the prime minister did not survive, the impact on the country would be huge.

Other people were not so kind in their thoughts and I heard a lot of anger towards Boris Johnson and the way that, people perceived, he had failed to protect them by not introducing lockdown measures earlier. One comment which stood out for me today was, “I hope that he doesn’t die though because otherwise it will be another Princess Diana moment and I couldn’t stand that”.

Day 21

Mary still struggles to hear that the shielding rules relating to the over-70s include her. She does not accept this from me or from her family.

Her Catholic faith has always been central to her life and she often refers to it being part of her core values. She is currently feeling angry that she is unable to attend church and is confused that, at a time when people need that support more than ever, it is not available to them. She described going to the church, expecting to be able to enter for some quiet private prayer, and how angry she felt that the door was locked, with no note or suggestions about alternatives.

Whilst Mary is still able to access streamed online services, she does not feel that she is part of a service but is simply watching the priest “going through the motions on my screen”. As this is Easter week, Mary is feeling particularly lost about how she can deal with facing the first Easter of her life where she was unable to attend church.

Easter is, of course, traditionally a time for family. I am personally finding it difficult not being able to spend time with our adult children who no longer live at home. I’m planning a Zoom Sunday lunch so that we can eat together in our different houses and at least see each other on screen to feel some connection and shared celebration.

Day 22

Meeting again with Dave and Hannah, I asked them how they found the video sessions, sitting close together to fit onto the screen. They both admitted that it was uncomfortable and I suggested that they join the sessions separately. They are continuing to find the lockdown extremely difficult and, once again, the tension between them is palpable. This is exacerbated by the fact that neither of them is able to physically leave the home for any substantial period of time.

When I was meeting with them face to face, they would have a babysitter for the children. Now we time the sessions in the hope that the children will be in bed, but the session today was brought to an abrupt end when the children got up and I did not think it appropriate for them to be in the background of the discussions. It may be that we have separate individual sessions for the time being.

Day 23

I am noticing that almost every session starts with the client saying “this is just weird”. It certainly is, but an exploration of what “weird” means for each individual client is a great insight into what emotions are in play when they are struggling to otherwise explain.

I often use a “Feelings Wheel” (developed by Dr Gloria Willcox) in my work with clients to explore emotions. We often use the same words to describe how we are feeling, such as “Angry”, “Happy” “Sad”, “Bad” or even “meh”. Using the wheel we can find a different and more accurate word and then this can change the feeling attached to the emotion. So if you think that you feel “sad” but then realise that you feel “powerless” this might change the way you respond to how you feel; for example, we can talk about what you can control in the current situation, no matter how small, to help take back some power.

I am hearing lots of clients saying that they don’t know how they “should” feel or that they are not feeling anything at all, they are just numb. We are all responding to this situation in different ways and at different rates and I am careful to remind them there is no right way to deal with this. We might all currently find ourselves in similar situations but we have all had different journeys and experiences to reach this point and therefore will all have different responses and coping mechanisms.

Day 24

The words “self-isolation” can make us feel disconnected from others. This was more apparent than ever when I had an appointment with Olivia. She is aged 25 and currently lives with her boyfriend and his family.

During the week since I had last spoken to her, she had found herself in a really difficult situation where she had visited her mother who was experiencing symptoms of the virus and, as a result, had been confined to her room when returning to her boyfriend’s home, as her boyfriend’s mother is in the high-risk category.

Olivia was really struggling with this “solitary confinement” and understandably experiencing it as a punishment. She only has access to her bedroom and the bathroom. When we feel vulnerable, we often revert to child-like behaviours and the current situation was reminding Olivia of being sent to her room as a child. She told me that she was struggling to cope and did not know how she would get through the week. I asked her about what she used to do as a child to soothe herself if she was worried or upset and whether there was a way of doing any of these things now, such as reading, painting, singing, dancing.

We talked about the things that she could still control – what time she got up, what she wore, how she did her hair, whether she put makeup on, where she went for her walk and what she ate. We talked about ways that she could introduce some structure into her day and I reminded her that the situation was temporary and that, by the time we spoke again, she would be able to move around the house.

I had a socially distanced coffee with my daughter today. She let herself into the side gate and sat in the garden at a safe distance, while I sat on the doorstep. It was a reminder for me of how important the face-to-face contact with people really is. It was so lovely to spend half an hour together in the sunshine, laughing and joking, but I also felt the ache of being unable to hug her.

Day 25

Meeting again with Jake, after a break of a couple of weeks. He is settling into his routine of working from home and feels more comfortable now that he has seen that he can still feel connected to his colleagues via technology. His workload has increased greatly over recent weeks and given him a welcome distraction. Jake is able to see now that, despite his initial fears, working at home is different to being confined to home due to his anxiety last year. He no longer feels “trapped”. For now, he feels safe and comfortable and commented that he is “no longer crying at adverts”.

Day 26

I am grateful for the opportunity that I have to speak with my supervisor fortnightly. All therapists have supervision, which is a chance for us to process our work with clients and to recognise and separate out our own feelings. In this time of a collective shared experience, this can be quite tricky. Lots of what I am hearing from clients, I am feeling, or have felt myself.

Supervision helps me to ground myself but also to freak out about how “weird” the current situation is. It is also an opportunity for me to process some of the vivid and disturbing dreams that I am currently having. I have realised that in spending the day working with others processing their thoughts about the situation, I do not really process my own.

Generally, day to day, I am feeling much more accepting of the current new normal but my brain is reminding me every night that I really am worried and frightened by the situation. I have decided that it might be a good idea for me to return to keeping a journal of some of my thoughts so that hopefully my brain might be less active during my sleep.

Day 27

I am noticing that there is generally a feeling of more acceptance of the current situation amongst many of my clients. I had been worried about the toxic impact of the forced positivity I have been seeing across social media (including from colleagues) about using this lockdown opportunity to learn a new skill, study more, make life-changing decisions and generally better ourselves. Initially, I was hearing clients panicking about not getting homeschooling right, balancing working from home and looking after children, feeling guilty about not doing something “productive”.

I am now noticing some clients finding enjoyment in small things in their day, such as shared meals with partners and children, going out for walks together, teaching children to cook, wash up, etc., allowing themselves to just sit and read a book for enjoyment rather than to learn something, and increased connection with friends and family by video calls.

This mirrors my own feelings about the situation. Before the pandemic, I was very hard on myself. I had worked hard to develop my counselling practice. I put myself under pressure to be the busiest and the best I could be. I was constantly thinking of ways to market my practice, learn new skills, gain more qualifications. With the enforced pause, I am now finding myself enjoying the slower pace, having space to be in the moment, focussing on the relationship with the clients without the need to grow my business and giving myself permission to read a book I want to read rather than feel pressure to do more training.

Day 28

Difficult conversation with Mike today before he embarks on the next stage of his cancer treatment, which is whole-brain radiation. We talked about his fears and I reminded him to think of his needs in the situation rather than future-proofing for everyone else, as is his tendency.

We discussed the fact that it was normal to be scared and apprehensive and also really angry about the situation. He is also feeling grateful that he is able to continue with treatment in the current circumstances and that he is also able to think about and discuss end of life, which he is aware that many people are not having the opportunity to do. It felt difficult ending the session today as I felt my own fears about how the treatment will impact on him and how he will be when we next speak (if we speak).

I have been aware throughout this period that many people are facing grief and loss, not necessarily in the form of losing loved ones. I wrote earlier in the diary about the “messy endings” that people are facing and these continue. Nearly all of my sessions are dealing with loss in some way… loss of normality, loss of freedom, loss of choice, loss of autonomy, loss of jobs, loss of privacy in our own homes, loss of routine and structure, and loss of physical contact and connection with others.

Whilst this is a collective loss and grieving, we will also be experiencing it in different ways, depending on our own previous life experiences. For many of us, this will also include loss of friends, colleagues, acquaintances or loved ones and it holds a certain amount of fear for me that my future work in coming months could be incredibly painful.

Day 29

I decided to pop into my office today as I needed to collect some papers and books. It was really strange going into a deserted office building that, until a month ago, I attended daily, and which was usually a buzzing environment of different businesses. There was an eerie calm and no signs of life.

Going into my therapy room, it was reassuring to see everything so familiar and comforting. I sat for a moment in my chair, which is much more comfortable than my old, falling-to-bits office chair that I am currently using in my spare room. It momentarily felt like a hug. Unfortunately, my plants, neglected over recent weeks, are dead, but can be replaced in the future. As I left, I quickly collected my scented tea lights. Maybe I need that familiar smell at home too. I am seriously now considering the possibility of building a therapy room at home so that I can continue my newly discovered work/life balance.

Meeting again with James and Emma. As Emma is in the high-risk category, she is not going out of the house at all. James is doing all of the shopping and Emma seems to be more reassured that he is taking the appropriate precautions to keep her safe. Both are working from home and busy during the day. James, however, raised his concern that they may have fallen into a pattern whereby they were socially distancing within their home. Discussing this with them, it was clear that they were both fearful of being physically close in case Emma became ill. This was causing some emotional distance in the relationship and so we focused on how they could feel connected again. It was interesting to notice that, even during the course of our discussion, they physically moved closer to each other on their sofa.

Day 30

We have now received the news that the lockdown measures will continue. I imagine that this will be met with mixed responses from my clients. I have started to get new client enquiries again, after nothing for about a month. Maybe people are adjusting and taking the opportunity to reach out for support. I anticipate that, as this situation develops, I will be very busy again. I have received the news today that a family member has tested positive for the virus, so I feel the reality of the crisis moving closer to home.

Reading back through this diary and the first entries, it really feels like a lifetime ago. I have been reflecting on what I have learned. Initially, I think I saw more intense emotions, particularly fear, anger and sadness. Counselling sessions are often emotional but this certainly felt as if someone had turned up the dial. As the weeks progressed, people seemed to settle and I was struck by how adaptable and resilient people can be. I am also cautious, however, that there may be some numbing of emotions as people need to get on with life and survive in this strange, new world.

I recently listened to a podcast by Dr Bessell Van Der Kolk, who is a trauma expert whom I greatly admire. He said that the preconditions for trauma are: 1. Lack of predictability; 2. Immobility; 3. Loss of connection; 4. Numbness and spacing out; 5. Loss of sense of time and sequence; 6. Loss of safety; and 7. Loss of sense of purpose. These are, of course, being experienced now by all of us, and I wonder whether, emotionally, we are experiencing the calm before the storm.

These preconditions for trauma can be useful guidance for us in trying to minimise the long-term impact of the current situation, for example: by looking at things that we can predict or look forward to; staying connected in safe ways; not numbing emotions with alcohol or avoidance; and trying to be mindful. Creating new structure to our day is important – getting up and going to bed at the same time, taking regular breaks for lunch and exercise. We can take precautions when we go outside and respect social-distancing measures, and bring our expectations a bit closer, finding purpose in day-to-day tasks for now, rather than expecting too much of ourselves.

These are all things I can continue to work on with clients – and myself.

Drawings by Zoë Barker

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