There’s a pandemic and people are dying and what if I get sick and my grandma dies and I lose my job and I start hating my kids and I run out of toilet paper and the economy tanks and I never see my friends and the hospitals shut down and this all goes on for months?

Clients sitting across from therapists — or now, looking at them through a computer or phone screen — are asking these questions and more as they navigate a health crisis that’s reached every corner of society and has no end date. Couples can’t get a break from one another. Parents have new roles as home-school providers. Seniors find themselves falling into greater isolation.

It’s an unprecedented time for therapists, too, as they and their clients experience something never seen in most people’s lifetimes. As one Seattle-area therapist said, providers “don’t get training in Pandemic 101.”

“This is new for all of us,” said Nathaniel Amos, another therapist with clients in Seattle and Burien.

While the pandemic has monopolized the conversation topics of many sessions, it’s also changed how therapist and client communicate, with laptops on tables replacing therapy couches. Amid a stay-at-home order and social distancing directive, many mental health services have moved to telehealth, in the form of video chats that come with their own set of pros and cons.

Clients describe a changing form of anxiety related to the outbreak. Michael Archer, a psychologist at Eastside Psychological Associates, explains the difference by comparing the pandemic with an earthquake. It’s easier, psychologically, to accept that an earthquake is coming, and that it could shake the region tomorrow, or in 100 years. The pandemic is more like an asteroid, Archer said, that everyone knows is hurtling toward Earth.

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“That asteroid we have identified, in four weeks, will hit us, and there’s nothing we can do about it,” said Archer, who is also the director of clinical training at Fairfax Behavioral Health. “That kind of anxiety is different. It’s a slow burn.”

Washington State Health Care Authority

Mental health resources

• For a life-threatening emergency: Call 911.

• For suicide prevention: Contact the National Suicide Prevention Lifeline at 1-800-273-8255 (TRS: 1-800-799-4889).

• For 24-hour emotional support and referrals: Contact the Washington Recovery Help Line at 1-866-789-1511 or the mental health crisis line at 1-866-427-4747 (for King County)

“This is a big deal”

The first step, Seattle-area therapists say, is acknowledging to clients that this is horrible for everyone, to varying degrees. A pandemic and lockdown are not what most people planned on or thought about. And with that, reassuring patients they’re not overreacting.

“You need to validate that this is a big deal and it’s not going away,” Archer said. “People don’t want to be perceived as overreacting.”

Clients come in with fears about the worldwide outbreak, listing off the newest stats they saw on Facebook just minutes ago and recounting what they read on Twitter about the deaths in Italy. With an overwhelming amount of information, the brain senses danger, producing stress hormones that never give the body reprieve.

So what are therapists to do when faced with clients’ anxiety about the pandemic? Focus on what the client can do that day.

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“People are understandably focused on too much of the big picture,” said Kira Mauseth, a psychology senior instructor at Seattle University and psychologist. “What we are really trying to emphasize is concentric circles of care. Focus on yourself and family, then neighbors, then community. Reach out only in those circles, because that’s what you have the energy and bandwidth for. It allows you to focus on what you can control. Anxiety is the lack of control.”

With other news events that have round-the-clock updates — say, a presidential election — therapists might recommend significantly curbing consumption to help with information overload. They can’t do the same with a pandemic, where orders from leaders and recommendations from health officials affect day-to-day life and change rapidly.

Jaya Ramesh reminds her clients they don’t need to consume news all the time. Ramesh is a counselor with Catalyst Counseling in Woodinville, where she works with individuals and couples.

“How do we let go of this shock to the system? How do we practice a media diet? These are conversations we are having across the board,” Ramesh said. “I’ve talked to multiple clients about how ‘Hey, is there a way to pause how much information you are taking so your body doesn’t always feel like it’s in danger? Go for a walk, dance it out, do something.’ ”

Seeing images that are familiar but changed — like an empty Pike Place Market — contributes to anxiousness for those who live or are connected to the region. It was hard for Molly Sanderson, who grew up in Seattle and is a sophomore at Amherst College, to see news footage of abandoned Seattle landmarks, and then photos of parks filled with people not adhering to social distancing recommendations.

“It’s frustrating because I know that’s happening and friends, and would like to be with my family right now but know that’s not the right thing to do,” she said. “That’s the hardest part.”

Isolation can be an accelerant for people with mental health disorders or other conditions. Therapists have emphasized trying to maintain connections, even if it’s just a single phone call.

Mauseth found this was a factor in resilience of the people she met during her trips to Haiti, where she trained earthquake survivors, and Jordan, where she worked with Syrian refugees.

“People want to be heard, feel supported and be listened to,” Mauseth said. “Resilience is made up of flexibility, connection and purpose. You have to be connected to someone who isn’t you.”

Other therapists have found similar factors in how their clients are coping with the pandemic. The first is whether someone’s normal coping strategies have been disrupted, or if they’ve remained intact.

“The introverts are saying ‘are you telling me it’s now socially sanctioned to stay home and talk to my cat? This is doable,’” Catalyst Counseling owner Katherine Walter said. “The extroverts are hurting.”

Perception of threats, to health, finances or something else also play a significant role. Stress is generally lower among those who feel relatively safe because they’re isolating or generally healthy, or have a stable job or source of income. Walter’s clients are seniors and those with chronic illnesses, so stress is high.

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The last is purpose and structure — either too little or too much.

“For some people, COVID-19 hits and it’s a complete lack of structure and perhaps work has been interrupted,” Walter said. “On the other end of the spectrum, it might be simultaneously home-schooling children and working from home and it’s too much purpose, too much structure, completely overwhelming. Folks who hit that happy medium are doing quite well.”

Therapy by video

Megan Brodsky, 23, has seen the same therapist since she was in the third grade. But last week was the first of what likely will be a regular routine of speaking to her through video.

“I was surprised that the talking portion of it wasn’t that bad,” said Brodsky, who is working from her Burien home. “I much prefer in person, but because I’ve been on video calls for work every day, I’m almost getting used to that form of communication.”

Mental health service providers are considered essential workers, which means they can continue to operate amid Gov. Jay Inslee’s stay-at-home order. But officials for large organizations like the American Psychological Association say therapists can, and often should, work remotely.

“It is critically important that psychologists are able to meet the needs of their patients and communities during this difficult time, without further increasing the risk of contagion,” Arthur C. Evans Jr., APA’s chief executive officer, said in a media release calling on states and insurers to move quickly in allowing clients and providers access to telehealth.

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Some insurance companies bill the same amount for a telehealth session as an in-office session, but nationally that varies depending on the insurance company, provider and type of session. A telehealth session must have a video component, for example, and a phone call is billed differently.

Virtual sessions allow provider and client to continue their sessions without an interruption and avoid potential COVID-19 exposure. Some clients like being able to speak in their own home. But for others, video takes away the intimate setting of a small office that’s considered a safe space.

For that reason, Amos was still seeing a few patients in his office before Inslee’s order but planned to move to telehealth once the directive was issued.

“To give a blanket directive, while useful for containing something that is deadly, radically misunderstands that home is not a safe place for all of us,” Amos said.

Some clients may be more inclined to share more during a video session because they feel there’s distance between the client and therapist, which feels safer. But therapists often rely on body language, which is harder to ascertain in a video chat.

For couples, the dynamic changes when they’re on one side of the screen and the therapist is on the other. Ramesh likes to ask couples to turn toward each other and speak and track their body language

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“There is a lot going on in couple’s therapy that could be lost,” Ramesh said. “It’s an interesting time, because we’re so distanced from so many people but so close to the person we have chosen to partner with. It will highlight the patterns that are entrenched more starkly than ever.”

As those patterns are highlighted, the therapists are aware the outbreak will be brought up in sessions even after people are allowed to return to work and businesses reopen.

“[Talks about the pandemic] will take up the majority of our time, if not all,” Brodsky said. “There are so many facets that this has affected me and my life. It will come up in different conversations, but will all relate to coronavirus.”

 

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