The Problem With Therapy in the COVID Era

In 2020, therapists may struggle to treat the anxious client.

Posted Aug 13, 2020

Since early spring, approximately 90% of my clients, adults and children alike, have brought up stress about some aspect of the COVID-19 pandemic. And I don't blame them, I'm concerned too! Their anxiety is focused on topics ranging from worry about getting the virus or losing their source of income, to panic attacks in the grocery store, academic frustrations, or an inability to attend grief support groups. These are hard topics to approach as a therapist because it involves two relatively foreign processes.

First, there's no question that we're all concerned about at least some aspects of the COVID pandemic. So, therapists need to be able to provide support and empathy without feeling the "compassion fatigue" associated with discussing the same topic across an entire day's worth of clients. While sharing at least a degree of my clients' anxieties about the pandemic makes it easy to empathize with their feelings, it also leaves me feeling somewhat stuck because there's not really anything I can do with my client in the session to alleviate the external pressure of the situation. Learning coping mechanisms, focusing on what we can control, and reminding ourselves what sorts of thoughts are helpful, meaningful, and productive are all interventions that have shown promise.

But at the end of the day, we're all subjected to constant reminders of the anxiety-provoking situation. From the news media and advertisements about wearing masks (humorous or not) to the mask hanging on our car's turn signal arm and the temperature checks when we enter businesses, day-to-day life is filled with near-constant anxiety stimuli. For people who have clinical anxiety about the COVID pandemic, it's the equivalent of an arachnophobe being confronted with spiders a thousand times a day. Not easy!

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The second problem with doing therapy in the COVID era is that some therapeutic tools associated with typical cognitive behavioral therapy (CBT) are rendered useless. CBT is the most well-known and utilized therapeutic intervention by therapists across a variety of training programs (social workers, psychiatrists, counselors, marriage and family therapists, and psychologists). According to the Mayo Clinic and Psychology Today, CBT is a therapeutic process that seeks to modify inaccurate beliefs about the world (termed cognitions) in an effort to change the client's feelings about a situation.

For example, if a client is concerned that his friends think he's unlikable, the therapist might propose to the client that it's rather unlikely that they would be his friends if they didn't like him in the first place. Hopefully, the client is receptive to this perspective and can enjoy his relationships more thanks to a more accurate cognition: "My friends must like me because they're hanging out with me right now!" But when it comes to CBT for treating anxiety associated with COVID, therapists need to be more creative. Because anxious thoughts about the pandemic are reality-based and likely not an "inaccurate belief."

Don't get me wrong, CBT is still a workable intervention for anxiety! Therapists may focus their efforts on modifying the cognition instead of challenging or negating the cognition. A client may say, "I'm afraid to go to the store because I might get the virus," and the therapist, recognizing the realism of that fear (despite the extremely low base rate of occurrence), may choose to ask the client "Is spending your time worrying about going to the store helping you live your life or getting in the way of it? What if you thought to yourself: 'I'm very brave for taking care of my family during a scary time.'"

But we've also lost much of our opportunity for conducting exposure and response prevention treatment. If a client reports that they have developed a severe anxiety about touching things in public, we can't, in good conscience, assign a behavioral anxiety hierarchy that would have them carrying out tasks like touching a door handle and then choosing not to wash their hands. And, for clients with social anxiety, it may be unwise for them to challenge themselves by enduring a large social gathering due to social distancing regulations.

Ultimately, therapy in the COVID era has forced me to get more creative. I've been using Youtube for exposure therapy and spending a lot of time explaining that just because a thought is "true" doesn't make it "helpful" (e.g., reminding ourselves of the ongoing death toll on a daily basis is likely not helping us go about our lives in a manner consistent with our values).

To find a therapist, please visit the Psychology Today Therapy Directory.