Psychotherapy After the COVID-19 Pandemic: What Can We Expect?
By Eric M. Plakun, MD
You can read Dr. Plakun’s column online addressing this topic in the Journal of Psychiatric Practice: “Psychotherapy in the Post-COVID-19 Era”
I've been giving some thought to what psychotherapy might look like when we finally get past this pandemic. It’s already been changed now. That is, we’re certainly doing a lot more remote therapy than we used to on Zoom and other kinds of applications. It's become the way it happens. Beyond that, it's clear that the stress that people are facing in relation to that pandemic–the loneliness, the isolation, the boredom, the anxiety, and fear about contagion and dying–are having significant effects on people with current conditions and causing new ones. There's an increase in suicide, there's an increase in domestic abuse–there are all kinds of problems that we're facing.
But I've been trying to think down the road a little bit, even down the road past survivor guilt–the notion that when this passes, I may have gotten through relatively unscathed but I might feel guilty about the fact that others haven't or the other way around. And I'm trying to think also beyond the things we don't even fully know yet, likely the possibility of cytotoxic injury from the virus that may have neuropsychiatric effects that will turn up either as symptoms in people in psychotherapy or with fear that they're going to develop the neuro-psychiatric sequelae.
I’m trying to think beyond that, I’m trying to think of what are the things we may face that are less apparent and where my thoughts go is the two different concepts that seem to me to be relevant to keep in mind: one is the concept of moral injury and the other is blocked mourning. Let me say a few words about these.
Moral injury comes from literature about combat. It's severe psychological distress that comes from a violation of the moral code that we have joined and that we’re a part of. It’s what happens when we have perpetrated, or we have failed to prevent, or we have witnessed, or we’ve otherwise learned about some kind of atrocity that violates a moral code. Although this comes from the world of combat in the military, it also could turn up in employment situations and this pandemic has already been pointed to as the kind of experience that may well be associated with moral injury. It’s not hard to imagine the way this could impact first responders, frontline people, people who have to make triage decisions about who gets a ventilator and who doesn't, people who are making decisions about the reuse of personal protective equipment (PPE) and have to make decisions that they may come to regret, people who make decisions about prematurely perhaps opening or for too long closing commerce in an area.
There's a lot of decisions made by individuals that will affect others that seem like they open the door to moral injury. It's an important issue partly because psychotherapists are people who may face their own experiences of moral injury. They may feel, in relation to the hospital they work in or the clinic, something about the way that hospital or clinic took a stance, or failed to, around something important in the pandemic. Moral injury becomes something quite important to hold in mind, particularly when it comes to the transferences that we face as psychotherapists. One way to imagine this occurring, is with what we might think of as idealizing transferences–a patient who comes in, who sees us as a healthcare worker and is filled with gratitude and idealization of us. Those are relatively easy to sit with, but there's sometimes rather defensive transferences that actually get in the way of getting to the real material that a person needs to bring into the room. The more difficult transference to face is probably the transference to us as those involved in moral injury. It's never easy to be experienced as a bankrupt, morally corrupt, authority and yet that may be something we will have to face in our role of therapists.
Our job is to take the transferences that come to us, not refuse them, not actualize them and put them into practice, but to be able to sit with them. In order to prepare for this kind of moral injury that may be coming down the road as issues in psychotherapy, it’s important for us to make a space to think about where we are as individuals in relation to moral injury and to get on top of that as best we can. And if we find ourselves in a complicated situation with a patient bringing, for example, a transference to us as someone who's a morally bankrupt, corrupt, authority who participated in some way in a moral injury as part of society, to be ready to seek consultation and turn to others to help us deal with those kinds of difficult transferences.
The other issue is blocked mourning. I think it’s important to think about: What are the parts of major losses when we lose someone we care about? I tend to think of three. First of all, there's the bereavement–the actual experience of losing someone. Secondly, there's a psychobiological process of grief–the crying, the sense of loss and despair, the yearning–the images that can be intrusive of the person who's passed. These psychobiological processes never go away, but they do subside over time. One of the ways we help move the grief along is through rituals that are part of our culture that are what we talk about as mourning. And for now, mourning seems to be quite blocked for people.
Too often we are faced with situations where someone has died in the hospital and not been able to say goodbye to their relatives and the relatives are left, the family is left holding that, unable to have a funeral. And although they will go through the experience of grief, they may not go through the experience of mourning. This is not only an issue for individuals and for families, but for communities and for nations. Blocked mourning becomes an important issue, on a much larger scale. For example, if we think of something like the Vietnam War–this was a time of great division in the country–a huge anti-war movement, a great deal of tension, and people choosing sides about where they were in relation to the war. And yet, those who died were dying anyway regardless of the politics. It was an important step for the country to have a successful memorial or monument arise out of this in the form of the Vietnam Veterans Memorial. Something that listed all of the names of those who died was successful in initiating a mourning process that could bring together people who were on different sides of an issue.
There are other important examples of these kinds of successful memorials on a societal level. The Holocaust Museum in Washington DC, the African American Museum of History and Culture is another good example. These museum/memorials brought together Holocaust Survivors and in the case of the African American History and Culture Museum, the descendants of slaves to bring their experiences of loss into shaping what the museum would be like, what the memorial would be like. This is separate from the design of the building and it helps also design the experience of those of us who visit such memorials in terms of the entry into an experience of mourning–to get something of their experience that we’re invited into when we buy a ticket and walk in the door.
On a societal level it seems to me we're going to have a lot of work to do around the issue of blocked mourning. Lest in the failure to move along, we find ourselves as a nation, or many individuals, many families, becoming caught up in perennial mourning, complicated grief, and other sequelae of mourning processes that aren't carried forward.
When I was a Fellow in training at Austen Riggs, I was given some oversimplified but really useful advice by one of my supervisors, Martin Cooperman. Martin used to say, “You know all psychopathology is loss, but all psychotherapy is mourning.” And that ability to help people face, in a safe place, the loss that they have endured, the grief that they have endured, and open up a process of mourning that helps them move forward and move on in their lives I think it's part of what resilience is about and part of what we as therapists are going to have to be able to be prepared to bring to the table in the post-pandemic world. Anyway, those are my thoughts and I thank you for listening.