Future Tense

Coronavirus Diaries: The Coronavirus Is the Ultimate Exposure Therapy for My Anxious Clients, and for Me

Two women sit behind hands holding a surgical mask that says "Coronavirus Diaries."
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Coronavirus Diaries is a series of dispatches exploring how the coronavirus is affecting people’s lives. For the latest public health information, please refer to the Centers for Disease Control and Prevention’s website. For Slate’s coronavirus coverage, click here.

As a New York City psychotherapist in private practice, I’m intimately acquainted with anxiety. In any given week, I encounter it in the forms of generalized anxiety, panic disorder, trauma-related worry, and specific phobias ranging from agoraphobia to emetophobia (fear of vomiting) to sarmassophobia (fear of dating and relationships).

As of late, the inescapable coronavirus has snuck its way into the mix, including for those not previously identified as “having anxiety.” This unique situation—a potential worst-case scenario that can be conceptualized as the ultimate exposure therapy—requires me to take a dynamic approach, in terms of both my clients’ well-being and my own.

To date, clients have expressed a wide range of responses to the pandemic. Some feel vaguely preoccupied and overwhelmed; others report excessive worry and nightmares; others still fear the worst-case scenario entailing contamination, succumbing to sickness, and even a slow, grisly death in the grip of the disease. While the details of COVID-19 may be novel, the themes of isolation and existential dread my clients face are not.

I keep thinking about the coronavirus as exposure therapy, something that is rarely my first-line approach but has its place in the catalog of modern psychotherapy. Simply put, it’s a behavior therapy in which you are exposed to the very thing you fear the most— think poop, cockroaches, and the like—until it feels nonthreatening. It’s reserved for clients who feel particularly plagued or even debilitated by their fears and seek immediate (or at least quicker) results. It’s abrupt, intense, downright uncomfortable and sometimes even gross, much like COVID-19 itself. I find myself wondering: Is there any way for us to think of the coronavirus in similar terms?

To be clear: I don’t mean that people who are anxious about it should expose themselves to the virus. But there is some utility in seeing this object of anxiety—one that exacerbates existing fears about illness, confinement, and even death—as something that could also help us adapt, depending on how we respond to it.

That is, of course, easier said than done. In a recent session, Jason, a 26-year-old man from the Bronx with generalized anxiety, shared with me about the insulating nature of 21st- century life for millennials and how the coronavirus exacerbates it. (Client material has been shared with explicit client knowledge and permission. Names and identifying information have been changed to protect privacy.)

Another client, Luis, a Puerto Rican retiree with anxiety related to his traumatic history and a recently diagnosed health condition, spoke similarly of his experience as a Lyft driver during the COVID-19 era. He loved the flexibility and income of the gig, but chiefly valued the sense of purpose and connectedness he derived from his job. As he had done with me for months prior to the pandemic, he waxed poetic about driving, emphasizing the relationships he formed with riders over the course of their trips together. They shared stories, laughs, and above all, a human bond, no matter how fleeting or superficial. This daily fulfillment contrasted sharply with his feelings about his previous career working in a Queens hospital. All of these connections uplifted him and allayed much of his stress and panic—something that he prescribed to himself. But because he has an autoimmune condition, he can’t continue to drive. He felt not only financially burdened by being forced to abandon his job but psychologically bereft—suddenly he’d been rendered impotent, and his meaningful human bonds abruptly broken.

Anxiety has been part of the human experience from the dawn of time, essential to the survival of our species and motivating us to evolve and thrive. In truth, anxiety is an adaptive response, a natural emotion that prepares us for danger and enables us to cope well under stress.

I’ve been going through an exposure of my own as day-to-day circumstances shift. At a moment’s notice, I’ve had to upend my business and transform my traditional face-to-face practice into a digital operation, all while maintaining equanimity for those who depend on me.  I’ve retooled the practice overnight (for instance, getting my clients onto HIPAA-complaint video chatting software, making sure contact numbers are current, sliding my scale down for clients who’ve just taken a huge financial hit, and juggling work and child care as my family self-quarantines), as I’ve worried that my clients might feel overwhelmed and jump ship. Much to my pleasant surprise, all of my clients save one are onboard with the changes; most have even thanked me. As we adjust appointment times and switch session formats to continue meeting, we adapt, bond, and strengthen our therapeutic alliance, known to be the biggest contributor to a successful therapeutic relationship, both in terms of its quality and outcome.

I’m also motivated by the notion that people need a guidepost for accepting uncertainty and tolerating worry, particularly in moments of heightened fear and unpredictability. American psychologist Marsha Linehan, known for developing dialectical behavior therapy, has coined the term “distress tolerance,” which broadly comprises a set of thoughts and techniques to be used when a situation is difficult or impossible to change. At this moment in time, the virus is still new, sometimes frightening, and certainly unpredictable. The best we can hope for is to accept that and the heap of uncertainty that comes with it  and prepare accordingly, be it at work, home, or out in the world.

All this might sound a little like what Anna Freud called intellectualization, a cardinal defense mechanism, and I’m OK with that.  We all have our defenses for a reason (again, think of anxiety as adaptive!), so I’m allowing mine to mobilize. I’m noticing and accepting them, and thus, moving forward with my own responses to the virus, be they professional or personal.  Generally, our stuckness is what leads to some kind of psychopathology—impairing anxiety or otherwise—so if we can find ways to enable movement for ourselves and others, we’re on the right track.

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