The healing power of therapy comes from a secure and trusting relationship between therapist and client, Covid-19 induced separation is the antithesis to this.

Psychotherapy and lock-down, by Anonymous 13.5.2020

“Being forced to relocate one’s practice, having phone sessions, and responding to personal questions are all indications of the changed treatment frame, conscious manifestations of the boundary alterations that take place, and a reminder that psychotherapy can never be business as usual after a shared trauma of this magnitude.

The above was written about Hurricane Katrina, but could equally be said for psychotherapy in the on-going crisis. When Covid19 hit the UK, I was nine months into an 18-month course of NHS art psychotherapy. Debilitating mental illness and unresolved trauma had forced me to give up university, a job, and eventually many volunteering roles, in order to focus on recovery. This
article contains some of my reflections on having therapy disrupted, from the perspective of a service user, and is written as if addressing the therapist. (Please note the therapist is wonderful and the article should NOT be read as criticism of her or NHS art psychotherapy!)

From the beginning I struggled to trust you, terrified of becoming ‘too dependent’ on services, but you reassured me it was normal to need to talk and feeling dependent was part of the healing process. You said I might worry about being abandoned, but for the first time I had people I could be entirely open with: “we need to feel understood as much as we need to breathe.” I
worked hard to trust you, to allow myself to be comforted by this new-found sense of safety and containment. Then coronavirus realised my worst fears and ripped apart everything I had begun to believe in.

The first week without face to face appointments, with an ‘unprecedented national emergency’ and lock-down looming, threw the inequality of our relationship into stark reality. You and the rest of my care team had become, albeit temporarily, as important to me as my closest family. I couldn’t shake the feeling that I wanted to wrap the three of you up in cotton wool and
keep you safe from whatever came next. (I resented myself for feeling that way about you rather than my actual family). I went over and over the very little I knew about your relatives… Where in the world did they live? Were any of them vulnerable, which would you be worrying about? But whilst I agonised, I was aware that to you I am just a case in a job with a service that could be
shut down or drastically changed and staff redeployed overnight. Only weeks before you’d reminded me that although the context might be professional, at the end of the day we were still two human beings with a genuine relationship and it was okay for us to genuinely care and worry about each other. Your words seemed ironic looking back, at the end of the day we were pawns in a much bigger game and you could too easily be taken from me.

Before lock-down: Safety and containment.

You were remarkably positive about continuing therapy remotely, but my doubts started creeping in. I relied on the routine of going and coming back from appointments, of having space outside the family home to talk. Almost everything that ever happened to me happened in this flat. The emotional and psychological abuse from my ex-partner was mostly by phone and
online and received here. It took months of work with you and the rest of the mental health team to break down my default position of telling the story without the feelings. I had slowly begun to acknowledge my emotions and share them with you, but that level of vulnerability is something I will never have around my family who are now here 24/7. I was given the option of
moving to 15 minute ‘holding’ sessions, but couldn’t decide. One of my two care coordinators was in self-isolation and cutting down support seemed inadvisable.

The second and third weeks (first two of the official lock-down) I tried to use our sessions to tell you how I felt about the current situation. I made artwork to illustrate a lack of containment and how broken everything feels. Yet by the end of the third week I was struggling to feel the connection I’m used to with you. I was self-harming daily and suicidal thoughts were increasing. At the
end of our session you suggested I make a picture of something from my past for next time. I was reluctant to go into anything traumatic on the phone, but you wanted me to try. I never did because that evening I started really losing it…

I’m coming to the conclusion that therapy doesn’t work when it’s inconsistent (variable session lengths each week, having the option to put it on hold). It’s the fact that you are expected to keep coming back each week – regardless of whether you think you don’t have anything of value to say, regardless of whether you think you really annoy the therapist and don’t deserve their
time, regardless of whether you believe no one can understand you at your most distressed – that makes therapy work, and hopefully eventually proves you wrong.

As I’ve got sicker and my thinking more distorted, it’s become impossible to communicate exactly how unwell I am. No one sees me twisting my hands or digging my nails into my skin in desperation. My care coordinators don’t notice how after trying and failing to convince them my thoughts are too confused to be trusted, I tune out and agree to everything they say for the rest of the call. We didn’t have these problems when we could sit in the same space. You question why the lack of face to face appointments is making me suicidal “We’re all in the same boat,” you say, “It’s hard for everyone but it’s not unmanageable.” I disagree, we may be facing the same storm but we are not all in the same boat.

You have the advantage of knowing far more about me than I do about you, and maybe that allows you to compensate for some of what is lost without face to face contact. You can question me as to which room I’m sat in, what are my surroundings, who else is in the flat? You know enough about my living circumstances to have a good idea what it might be like. I want to ask you
the same things. Where do you sit, is it weird for you talking to service users from home? Who else lives in your house, do they ever make a noise and distract you? I daren’t ask, I’m not sure where the boundaries lie in this strange new world.

You can ask me how I’m feeling and what I’m thinking, but I took my knowledge of you from smaller things: The rare occasion you didn’t finish your tea before I arrived and you’d sit with both hands clasped around your mug. We had a fire drill in the rain and you kept smoothing down your hair and looking stressed. The week before your wedding, in contrast to your usually
perfectly neutral body language, you were fiddling with the edge of your lip, your engagement ring and your hair. Things like this were what reminded me you were human, sometimes self-conscious and occasionally distracted, that you were like me.

Maybe you think I’m only saying all this in retrospect, shaken by the loss of face to face contact and now overstating its importance? I wish that was true. Somehow noticing these little things and taking comfort in them made exposing myself to you more bearable. Therapy is hard at the best of times, and just as different people might learn best by reading, listening or doing, I
seem to rely on visual things and my surroundings to feel safe. I (accidentally) memorised every outfit, jewellery and hairstyle combination you had from week one and would list them back when I needed to stop a panic attack. “Offices are the physical containers of treatment, the familiar places where patients find sanctuary,” Boulanger wrote. And at weekends, as a last resort
before dialling 999 or going to A&E, I would sit in the cafe of the hospital site where we had appointments. I knew these things weren’t long-term solutions, but they were getting me through the worst of the feelings therapy brought up and I was making progress.

Ripped apart: no longer containing?

Usually it is me who downplays the severity of events, whilst you point out that something would have had a much bigger impact than I’ll admit. It is you who acknowledges that I might well have felt scared or hurt or abandoned, whilst I accuse myself of overreacting. Now I’m trying to find ways to explain this feeling that something isn’t working. You keep reassuring me that you ‘haven’t disappeared’, you and the offer of therapy are very much still there. You say phone appointments are really not that different, we can still talk, you can still help me process my past, if that’s what I want to do. So why after our phone calls do I feel confused and guilty that your reassurance hasn’t helped, rather than validated and accepted?

The best I’ve come up with is that when I say I’m struggling to cope, phone calls aren’t really helping and I need it to be face to face to be psychotherapy…. What I’m feeling is grief for our in-person relationship, and the distress of being ‘abandoned’ just when I’d learnt to depend on you. Your downplaying of the importance of our face to face relationship means you can’t help me get over that loss. Therapy is supposed to help you process the feelings that are overwhelming you in the rest of your life… But how do I use our sessions to feel grief for YOU, especially when you’re telling me that you’re still here and it’s just the same!? When we’ve talked about feeling abandoned before, it’s always been with the (unspoken) assumption that you are not someone who will abandon me. Is it harder for you to hold my distress now your on-going, yet involuntary, abandonment of me is the cause?

Five years from now, I anticipate your colleagues publishing learned journal articles, ‘Psychotherapy Outcomes In A Global Pandemic’ ‘How Lock-Down Impacts The Therapeutic Relationship’, I intend to be long free of services by then.

I hope we get through this, the shared experience could even strengthen our therapeutic relationship. More often though, I fear I am no longer helpable. I worry you may never be separate enough from this situation to acknowledge my feelings about it, and I will live with the knowledge that what should have been safe and consistent enough to hold me, instead added to a list of
traumas and proved no one can be depended on.

So where do we go from here? Let’s at least acknowledge that this cannot be “business as usual”. Shared trauma will have changed the boundaries of the therapeutic relationship and disrupted the sense of safety and containment patients are encouraged to rely on. Many of us have not only had our routines and coping strategies disrupted, but old wounds reopened. If the healing power of therapy comes from a secure and trusting relationship between therapist and client, Covid-19 induced separation is the antithesis to this. We need reassurance, but we also need our experiences of on-going disruption and abandonment validated. After all, isn’t recognising what’s happening in the room – now phone call or video – what psychotherapy is about?

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