Confessions From Your Zoom Therapist: Do Diagnoses Matter?

This post was written by Courtney DeAngelis, Psy.D.

I wait for my patient’s face to emerge in the black box on the screen, hoping for a good Wi-Fi day. I hold a smile and do not offer any verbalizations until I’ve read confirmation that she has indeed connected to audio. I suppose this is the 2021 equivalent of my routine distant smile to a patient from down the hall; I would never dare to ask about the weather until we were in closer proximity.

Today, I see her coca-cola eyes a little less vividly on the video call. Today, I see that she is a storm. She quickly shares how today has not been good at all. She is furious that her little brother would dare to sit on her bed while wearing his “daytime clothes,” especially after attending school all day. She demands that her sheets be washed, and even then, it still may not be safe for her to sleep on “the safe side” of the bed. I have never heard of these rules before and am just learning how she has guarded her space from other family members.

Source: Kelly Sikkema/Unsplash

Therapy in the COVID era

If she had described such fears about germs pre-COVID era, I would have nodded my head as I pressed my black pen to my Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) Checklist. Now, I query more about her routines before I proceed. I ask, “Do you change your clothes as soon as you come home and keep the new pair on throughout the afternoon? Can you touch the clothes in your hamper? Are you following the school rules for hand washing, or would you say that your brain is a little bit greedy with the soap, and you sometimes take extra? Do these worries about germs pop up when you are inside, outside, or both? When your mask is on or off? While you’re with a big or small group of friends?”

I want to better understand the intricacies of her world, as it seems as though all of my patients have developed some contamination obsessions or illness anxiety since COVID hit. The already messy DSM-5 diagnostic system is now even more muddied by the chaos of these “unprecedented times”—a term that has become our endearing cognitive reframe for the dumpster fire that 2020 and 2021 have been. And yet, during an incredibly disorganizing pandemic, I am eager to look to a guiding system to make sense of what my patients are going through. This makes me wonder: Do I gravitate toward diagnoses because they improve my clinical work, or do they primarily alleviate my anxiety?

We coined the terms "Zoom Fatigue" and "COVID Burnout" early on in this pandemic, perhaps to shed some insight into our current emotional experiences. This language can help some to understand why they may be feeling so exhausted and run down. We have also already offered strategies and tips to the general public to combat these symptoms. We are all undoubtedly looking to alleviate some distress.

As a psychologist who practices exposure and response prevention therapy, I traditionally guide my patients to lean into the chaos and confront their fears head-on. Despite my efforts to confidently lead patients through this pandemic in a manner that will reduce anxiety, I often feel like I am swinging at a piñata, blindfolded. And when I take off the blindfold, I am left to find the stuffed unicorn laughing at my repeated misses as it sways in the wind.

I never imagined that I would be attempting to calm my patients’ fears in the midst of a global pandemic during my first two years as a faculty psychologist. And trust me, I had dreamed up plenty of irrational fears as a graduate student when I fumbled my way through every evidence-based treatment manual that I could get my hands on.

Diagnostic challenges during a pandemic

Children, teens, and young adults continue to look to me to make sense of what they are experiencing, provide support, and offer new tools to add to their toolbox. I have my own internal filing system to recall sessions and distinguish between my patients. Truthfully, my brain feels very much like a crowded attic at the moment. I’ve struggled to update the file folders of my existing patients, who now have many overlapping fears and may no longer quite fit into the traditional anxiety disorder diagnoses.

But perhaps, I don’t need to revise the diagnoses or press my black pen so urgently to the CY-BOCS checklist. Instead, I can consider the following:

• Remain present with my patients. Listen to the details of their successes and challenges from the week as they ride the many waves of this pandemic.
• Model a willingness to tolerate uncertainty. Resist the pressure to label a patient’s increased attention to germs as “OCD” or quickly change their diagnosis.
• Identify the function of the problematic or distressing behaviors to target in treatment with patients.
• Collaborate with patients to set small, tangible goals, knowing that some may change fluidly in response to ongoing COVID-19 stressors.

Source: Courtney DeAngelis, Psy.D.

My patient finally finishes sharing her list of grievances with me. I reply, “Man, little brothers are really the worst sometimes! Let’s figure out how we can boss back those worries and get you feeling comfortable in your bed tonight.”

Courtney DeAngelis, Psy.D., is a licensed clinical psychologist at the Columbia University Clinic for Anxiety and Related Disorders (CUCARD) - Westchester. She received her doctorate from LaSalle University. In addition to conducting psychotherapy, she also provides supervision to doctoral students at various stages of their training.

Dr. DeAngelis specializes in the assessment and treatment of children, adolescents, and young adults with anxiety and related disorders, OCD, post-traumatic stress, and school refusal. Dr. DeAngelis has more recently received specialized training in the treatment of complicated grief.