Internet Editor’s Note: Dr. Shapiro recently published an article “The Art of Bohart” which can be found in Psychotherapy Bulletin.
Despite vaccination roll-out for the COVID-19 virus and re-entry into “normal life,” reports of anxiety, depression, and posttraumatic stress disorder (PTSD) are rising with those in lower socioeconomic status (SES) strata and young adults most likely to bear disproportionate incidences of life disruption. This pandemic, which is far from over, created a perfect storm as people are forced to confront several existential questions simultaneously. In this paper the authors pose some existential therapeutic answers.
Recommended interventions include acknowledgment and normalizing of existential anxieties around mortality, rebalancing the tension between security and freedom, addressing loneliness from isolation, and exploring life-meaning. Considerations of the benefits and costs of emotionally-driven, security-based adaptations are seen as precursors to a psychologically healthy rebalancing of internal needs. These are best accomplished within a therapeutic relationship that introduces existential concerns, emphasizes teamwork, and witnessing of the difficult steps toward a more freedom-oriented orientation.
Existential Psychotherapy for an Existential Pandemic
By July 2021, the World Health Organization conservatively reported 185 million cases of COVID-19 and 4 million deaths (WHO, 2020). Those numbers will increase until the pandemic gradually fades or is brought increasingly under control.
Unanticipated and uncontrollable traumatic events such as natural disasters, wars, economic depressions, government upheavals, and pandemics stimulate insecurity and new foci on mortality and life meaning. Frankl (2006) famously noted that although individuals do not have control over what occurs in their lives, they do have freedom to choose how to respond to such disruptive events.
COVID-19 and its sequelae certainly qualify as a significant life-altering event. Among the psychological realities are increases in insecurity, anxiety, depression, and incidence of PTSD. According to Weissbourd et al., (2021), 36% of all Americans, including 61% of young adults between the age of 18-25 and 51% of mothers with young children reported being miserably lonely – an experience exacerbated by social distancing and fear of contagion. Social isolation is related to an increase in morbidity, mortality, and a substantial decline in mental wellness, (Hawkley & Cacioppo, 2010).
Moreover, Bai et al.’s reporting on the 2003 SARS outbreak concluded that quarantine implementation was an important predictor of PTSD and Ingram et al., (2020) elucidated the strong link between social isolation and depression, anxiety, and substance abuse. The virus not only created an ominous threat to health and life, but the necessary accommodations forced confrontation with several other existential concerns, including isolation, issues of freedom and responsibility (i.e., potential for spreading the disease) and challenges of dealing with life’s meanings. These issues comprise the entirety of Yalom’s (1980) “givens” of human existence.
From an existential perspective, these givens usually are confronted developmentally through the course of life (Shapiro, 2016). What COVID-19 has wrought is a sudden need to confront all of them simultaneously – a “perfect storm” of all the elements as if in a pressure cooker. This creates significant unpredictability in life, resulting in feelings of insecurity, anxiety and depression, and a natural withdrawal into protection and security.
As Shapiro (2016; 2021) has described, there are constant tensions balancing core needs for freedom and security at both macro (lifelong) and micro (momentary) levels. Normal healthy functioning requires ongoing adjustments in this essential balance for psychological growth, similar to Piaget’s (1967) cognitive assimilation-accommodation cycle. COVID-19 and its sequelae have forced a security-oriented imbalance of that tension. Individuals sacrificed many aspects of personal freedom, particularly around contact with others while “sheltering-in-place.” Trivial decisions like whether to eat at home or dine out suddenly seemed potentially life-threatening. In addition, feelings of isolation were amplified by travel restrictions and loss of physical contact with families and loved ones.
These protective adaptations are not dissimilar to the emergency biological response of the sympathetic nervous system for fight or flight in the presence of imminent danger. Life-preserving adjustments are primarily intended for emergencies. When they persist for a considerable period of time, systems break down and rebalancing corrections may take a significant period of time. There is a negative correlation between length of quarantine and psychological outcome (Brooks et al., 2020).
According to the US Centers for Disease Control and Prevention (CDC), anxiety and depression increased dramatically (11%) from Spring, 2019 to 31% during the Spring of 2020 in the wake of the pandemic. In June 2020, 60% of young adults age 18 to 24 were estimated to be at risk for depression or anxiety and a quarter reported considering suicide in the previous month (Czeisler et al., 2020; Giuntella et al., 2021). These findings correlated with the prevalence of stay-at-home orders and rising illness and death totals.
Although the mortality rate in the U.S. have come down, the number of mental health concerns have remained high. From August 2020 to February 2021, the percentage of adults with symptoms of an anxiety or a depressive disorder increased from 36.4% to 41.5% (Vahratian et al., 2021) and there was also a substantial increase in reports of domestic violence (Usher et al., 2020). An APA Stress in America Series poll in April, 2021 reported a 41% increase in anxiety in a year. There is considerable evidence that these symptoms will not quickly abate with vaccinations and re-entry. In their systematic review and meta-analysis of worldwide prevalence of PTSD after large-scale pandemics, Yuan et al. (2021) estimate that approximately 22% of the population will experience PTSD.
Given the prevalence of the crisis and psychological stress, treatment options may have to be carefully reconsidered. To be maximally effective, therapy may have to directly address these existential issues (i.e., mortality, a need to find/create meaning, freedom, loneliness or conversely, lack of personal space).
This consideration must also occur in the context of a widely segregated and divided U.S. culture, battles over vaccinations, COVID-19 deniers, and a dramatic disparity between populations who have been inordinately impacted by the terrors of COVID-19 (Stokes et al., 2020). Those who have been most impacted come from the lower SES strata of society, who have less ready access to treatment. They have suffered the most death, the most job disruption, and the greatest threat to income and living conditions. Many are also “essential workers” with the greatest exposure to the disease (Krahé, 2020).
Approaches to Therapy
A recent dramatic increase in need for therapeutic intervention is being hampered by increased caseloads for therapists and by being mediated by remote access (telehealth), that is impacted by the loss of in-person data, the vagaries of internet connections, distractions in a home environment, and “zoom fatigue.”
We posit that regardless of the theoretical approach used, existential issues must be explored and effective therapy requires more than symptom reduction. Clients’ interpersonal relationships must be addressed (i.e., Pietromanco & Overall, 2021) and the relationship with the personal therapist may be more essential (Norcross, 2011; Shapiro, 2016).
Therapeutic Interventions for Re-entry and PTSD
COVID-19 has pressed people to face, more poignantly their fears of mortality and with the need for life-preserving adaptations. Yet, although protective isolation is beneficial, it intensifies additional existential concerns; tilting the balance towards security needs while limiting access to expressions of freedom and intensifying questions about the meaning of life. Although symptom reduction may be an initial (necessary) goal of any treatment, it may be insufficient for those suffering from COVID-19 related distress and PTSD. Happiness and well-being are more complex, require balance, and the capacity for intimacy.
Enhanced sensitivity to fears of mortality and the random, unpredictability that accompanies this pandemic may have to be introduced by the therapist as factors in the clients’ experiences, symptoms, and presentation. Once opened, therapist acceptance and normalizing of the subjective vulnerabilities is most germane. An approach that enhances clients’ recognizing the limits of the human condition, the salience of making meaning in life and living more fully in the present will be particularly heuristic.
To address the impact of isolation. Therapists need to encourage a counterbalancing therapeutic alliance. By acknowledging the “real” suffering, and the myriad losses incurred during the pandemic, (losses of friends and family members, long term impact of affliction, career opportunity lost, financial woes, a disorienting sense of instability, and unpredictability in life), therapists and clients can explore together the consequences of survival adaptations, current protective behaviors and the implications of continuing with the pandemic status quo lifestyle. Once those strategic actions have been honored, can the resultant imbalance in the security-freedom continuum be re-attuned.
However, any adjustment of these tensions threatens the status-quo, which although no longer germane, may still feel necessary. Interventions will involve awareness of those powerful emotionally-driven and security-focused reactions to the pandemic that persist despite being currently anachronistic and extracting an excessive cost by restricting fuller functioning. Any security-dominated mindset will likely be quite resistant to change. Shifts from freedom will inevitably exacerbate fears of the unknown.
These fears may be best addressed counter-intuitively. Therapists can support the security side by acknowledging this very real need and consequent adaptive behaviors. When their security needs are assured, clients are more able to explore their needs for increasing freedom, and resetting the balance with small experiments (Shapiro et al., 2019). Where the disruption of social interaction has involved feelings of being suffocated in a 24/7 relational environment, those experiments might involve finding individual spaces within a relational framework.
By engaging clients in a phenomenological environment that allows for mutual comprehension of the trauma and resultant symptomatology, a safe therapeutic relationship can be created in which clients can try out new or pre-pandemic behaviors to develop a greater sense of life’s meaning. In doing this, therapists will need to distinguish between existential anxiety, stemming from life’s unknowns that are necessary to accept as part of life, and neurotic anxiety (fear of fear that blocks attention to existential anxiety), which is best confronted and worked through (Shapiro, 2016). Once that is realized, therapists can encourage modest approaches to facing fears of the unknown and choices about how to respond (Frankl, 2006). Exploration of existential anxieties may then become an engine of growth. Finally, this type of treatment demands that therapists be in contact with the anxieties in their own phenomenological worlds and are able to share some of them in-session process with genuine care and empathy.
In summary, existential psychotherapy with clients experiencing COVID-19 oriented disruption will focus on and enhance the person-to-person relationship, honor, and support the clients’ subjective realities, normalize existential anxiety and survival-based protective reactions to the pandemic and explore the meaning given to the events of the “COVID-19 year."
Cite This Article
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