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Psychotherapy in the Post-COVID-19 Era

PLAKUN, ERIC M. MD

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Journal of Psychiatric Practice: July 2020 - Volume 26 - Issue 4 - p 309-312
doi: 10.1097/PRA.0000000000000476
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Abstract

The pandemic of coronavirus disease 2019 (COVID-19) is a devastating event that has transformed contemporary society and commerce. Authorities offer overlapping but not always fully congruent recommendations about responding to the virus and how to flatten the curve of infections, with strongly held opinions often expressed ahead of established facts, and sometimes not enough personal protective equipment (PPE) available to protect those on the front lines or enough ventilators on hand to treat the sickest patients. In some areas, health care systems have been on the brink—or past the point—of being overwhelmed, and sometimes the sheer magnitude of death and loss, combined with the impact of the illness itself, contributes to the death by suicide of those providing treatment.1

The national economy has been thrown into deep recession, with millions who, in the best of times, live paycheck to paycheck, facing loss of employment and interruption of their social and financial support systems. Tens of millions of newly unemployed individuals are struggling to deal with the overwhelmed online interfaces of our social safety net as they seek access to benefits. Shelter-in-place orders, the boredom, loneliness, lack of structure and meaning in life associated with such orders, and the relentless news cycle in media and online covering the COVID-19 crisis, often combined with the need to homeschool children, make daily life stressful and burdensome. Domestic abuse and suicide are on the rise.

Meanwhile, the practice of psychotherapy has been transformed. Virtually overnight, and across the nation, psychotherapy sessions became remote access virtual meetings instead of in-person encounters, with new best practices emerging in real time. For many patients, having a therapist for remote therapy is a prized possession, while, for many therapists, having patients to tend to remotely gives life meaning, purpose, and a way to be of service, while providing a financial lifeline.

Someday, in a year or perhaps several, the pandemic will subside, and life will return to a revised version of normal because of a vaccine or wide enough spread of disease to achieve herd immunity and/or successful treatment strategies. In this column, my intent is to try to look around the corner to that time in the hope of offering some informed speculation about what psychotherapists might face in the post-COVID-19 era. This perspective is not meant to be comprehensive as much as it is meant to try to highlight what might otherwise escape our attention.

It seems clear that preexisting mental and substance use disorders will be exacerbated by the degree of adversity and stress experienced by many, and that this adversity will also contribute to the onset of new disorders. Similarly, the novel coronavirus seems to cause cytotoxic injury to more organ systems than the respiratory system, with hints that it may be associated with yet undefined neuropsychiatric problems. There are, for example, suggestions that the Spanish Flu of 1918 may have been associated with an increased incidence of Parkinson disease in flu survivors decades later. Uncertainty about such neuropsychiatric sequelae, or their prodromal phases, may well become part of the experience of future psychotherapy patients.

Similarly, survivor guilt will likely become a prominent issue. One might feel relief to get through this period with self and loved ones safe and employed, while unaffected directly by death or economic hardship beyond a period of sheltering in place, but that relief might easily evolve in the direction of survivor guilt given the devastating experiences of others. These seem obvious sequelae of the pandemic relevant to psychotherapy, but I want to address 2 other issues that might be less apparent.

MORAL INJURY

The concept of moral injury has its origins in the traumatic experiences of war. Litz et al2 defined moral injury as intense psychological distress resulting from “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”(p700) When a moral code that we have joined is violated by us or by others, or by those we depend on to uphold that moral code, we feel a connection to that violation in the form of distress that may be substantial.

Others3 have already recognized that the COVID-19 pandemic is a potentially morally injurious event. They note that moral injury is not limited to experiences of war, but that it may also be part of employment experiences. Although moral injury is not itself a mental disorder, the experience of moral injury is associated with negative thoughts about others or oneself, including shame, disgust, and guilt. Moral injury is associated with the subsequent onset of mental symptoms or disorders such as depression, anxiety, or posttraumatic stress disorder.4

In the postpandemic period, and even before the pandemic ends, psychotherapists are likely to see significant distress in patients related to experiences of moral injury. It is easiest to imagine the importance of moral injury in frontline responders making triage decisions and tending to the emergently ill. Making decisions about whom to put on a ventilator, who gets access to PPE, how to deploy personnel and other limited resources, and about separating the ill, perhaps for the last time, from those they love, clearly includes the potential for experiences that violate our moral code, regardless of the practical exigencies that may require such decisions to be made.

However, it is not just frontline personnel who may experience moral injury, as this is also an experience felt in relation to failing to prevent or learning about such events. Some will feel a sense of moral injury in relation to leaders at the family, community, hospital, or government level who failed to anticipate, properly respond to, or prevent the pandemic and its consequences—or may feel responsible because of their own family or leadership roles. How could I have sent my loved one to the emergency room for urgent treatment only for us to be separated and have her die alone days later? Did I make the right decision about requiring the re-use of PPE that had been designed for one-time use? Why did I decline to test residents of the nursing home that subsequently had multiple deaths? Did I suspend restrictions for the business, city, state, or nation for which I am responsible prematurely, only to have a second wave of illness follow? Will I ever again be able to feel good about a governing entity that failed me/us so seriously? Was I an asymptomatic carrier all along?

Psychotherapists are not immune from moral injury. Of particular relevance for us may be the countertransference phenomenon associated with our own sense of moral injury and how we may share patients’ sense of moral failure directed toward themselves or others, or toward us. We are likely to face idealizing transferences that are gratifying (I appreciate all of you essential health care providers so much) or quite hard to endure (You sat this out comfortably in your office while I risked my life every day working as an ICU nurse). We are well-advised to avoid basking in transference idealization that may serve a defensive purpose, while we also must avoid refusing unpleasant negative transferences, given that part of our role as therapists is to take the transference as it arises.5

In addition to being aware of the impact on our patients (and ourselves) of moral injury, we are well-advised to anticipate the emergence of transferences to us as moral injurers. It is burdensome to be seen in the transference as a corrupt and morally bankrupt authority, but being able to sit with these transferences is part of a dynamic therapist’s task. Preparing for these situations by creating a space to reflect on our own experiences of the pandemic may allow us to be better therapists for those struggling with moral injury. Such preparatory efforts, as well as consultation when difficult situations arise, may help ward off secondary traumatization and burnout in the post-COVID-19 era.

BLOCKED MOURNING

First, it is important to distinguish between bereavement, grief, and mourning, which are differentiated components of the response to loss. As Shear6 noted, bereavement refers to the experience of losing someone close, while grief is the psychobiological response to bereavement, including sadness and yearning, along with thoughts, memories, and images of the deceased person. Although we never really stop grieving a loss, its intensity usually subsides over time through various psychological processes and cultural rituals that are what we call mourning.

The pandemic is associated with numerous deaths and hence with substantial bereavement and grief. COVID-19 deaths often occur without the possibility of a goodbye between the dying individual and loved ones. People are dying alone, sometimes comforted by medical personnel, sometimes not, sometimes with a FaceTime farewell with loved ones, sometimes not. While the survivors of such losses are bereaved and filled with grief, their access to personal goodbyes and culturally congruent mourning rituals such as funerals is foreclosed by the same pandemic that caused the death. Although the physiological and psychological processes of grief will unfold anyway, mourning will be blocked not only for many individuals, but also for families and larger groups like communities and nations.7

Hence, in the aftermath of the pandemic, therapists are likely to see an increase in those suffering from complicated grief, perennial mourning, and other manifestations of blocked mourning processes.7 Given these personal, intrafamilial, and cultural dynamic processes involving blocked mourning, there will likely be an impact on many individuals, some of whom will carry these and other issues into their psychotherapy. We will have work to do with many of our patients to help them engage the reality that, although their acute grief about a pandemic-related loss may have subsided, their personal mourning process may have been blocked, and may be incomplete or perhaps not even begun because of foreclosure of social mourning rituals.

Mathematician George Box8 taught us that all models are wrong but some are useful. An early supervisor from my time in fellowship training at Austen Riggs, Martin Cooperman, offered me a good example of a wrong but quite useful model that will, I believe, become increasingly useful in the postpandemic world. Cooperman taught that “All psychopathology is loss; all psychotherapy is mourning.”

As noted above, beyond the level of the individual, the lack of access to ritualized mourning events will likely also contribute to manifestations of blocked mourning for families and larger groups, including communities and nations. As a society we would be wise to make efforts to unblock mourning on a large group level, perhaps through large group rituals and/or development of appropriate and successful monuments or memorials to symbolize the losses and free up mourning processes, lest we become stuck in perennial mourning.7 The Vietnam Veterans Memorial, the United States Holocaust Memorial Museum, and the National Museum of African American History and Culture in Washington, DC are examples of relatively successful public monuments that help unblock mourning processes—in timely (eg, the Vietnam Veterans Memorial) or not so timely (eg, the National Museum of African American History and Culture) ways.9

Successful monuments are more than structures, though. The Vietnam Veterans Memorial, for example, appears to have been a success precisely because so many who fought in the war, lost loved ones in the war, and/or supported or bitterly opposed the war in a divided nation, find that the monument speaks to their experience and brings together all perspectives by honoring those lost. Individuals with knowledge and understanding of large group processes will have an important role to play in developing such monuments to help repair, on a societal level, the damage done by so many deaths occurring in ways that did not allow culturally sanctioned mourning processes to unfold.9

The degree of inclusiveness of the processes used to plan, design, and curate monuments and memorials also plays a central role in whether they succeed on a societal level. The United States Holocaust Memorial Museum and National Museum of African American History and Culture are examples of monuments that are successful in part because of the way they invited the feedback and involvement of Holocaust survivors and the descendants of slaves, respectively. This feedback was used to design and plan the buildings, but also to bear witness to the traumatic losses of those whose experiences are memorialized by them, and to plan the significant mourning process those who visit are invited to enter.10,11

ACKNOWLEDGMENT

The author thanks Julia Thomas for her help preparing this manuscript.

REFERENCES

1. Top E.R. doctor who treated virus patients dies by suicide. New York Times. A version of this article appeared in print on April 28, 2020, Section A, page 13 with the headline: ‘Truly in the trenches,’ doctor dies by suicide. Available at: www.nytimes.com/2020/04/27/nyregion/new-york-city-doctor-suicide-coronavirus.html. Accessed May 8, 2020.
2. Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. 2009;29:695–706.
3. Williamson V, Murphy D, Greenberg N. Editorial: COVID-19 and experiences of moral injury in frontline key workers. Occup Med. 2020;Apr 2:kqaa052. doi:10.1093/occmed/kqaa052. [Online ahead of print].
4. Williamson V, Stevelink SAM, Greenberg N. Occupational moral injury and mental health: systematic review and meta-analysis. Br J Psychiatry. 2018;212:339–346.
5. Plakun EM. Making the alliance and taking the transference in work with suicidal borderline patients. J Psychother Pract Res. 2001;10:269–276.
6. Shear MK. Grief and mourning gone awry: pathway and course of complicated grief. Dialogues Clin Neurosci. 2012;14:119–128.
7. Volkan VD. Linking Objects and Linking Phenomena: A Study of the Forms, Symptoms, Metapsychology and Therapy of Complicated Mourning. New York, NY: International Universities Press; 1981.
8. Box GEPLauner RL, Wilkinson GN. Robustness in the strategy of scientific model building. Robustness in Statistics. New York, NY: Academic Press; 1979:201–236.
9. Volkan VDBarkan E, Karn A. What some monuments tell us about mourning and forgiveness. Taking Wrongs Seriously: Apologies and Reconciliation. Stanford, CA: Stanford University Press; 2006:115–131.
10. Gould LJ. Collective working through: the role and function of memorialisation. Organ Soc Dyn. 2011;11:79–92.
11. Shin A. The Story Behind the Design of the African American History Museum. Washington, DC: Washington Post; September 15, 2016. Available at: www.washingtonpost.com/lifestyle/magazine/the-story-behind-the-design-of-the-african-american-history-museum/2016/09/14/e08b1b4e-4ddb-11e6-a422-83ab49ed5e6a_story.html. Accessed May 6, 2020.
Keywords:

coronavirus disease 2019 (COVID-19); pandemic; moral injury; blocked mourning

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