Therapy under lockdown: ‘I’m just as terrified as my patients are’

In a pandemic, the best we can do to take care of one another is to stay away from one another. Even Freud at his most misanthropic could never have come up with that.

by Gary Greenberg [1]

For the 35 years I have practised as a psychotherapist, I have discouraged people from seeing themselves as hapless victims of forces arrayed against them. That’s the whole premise – that whatever brought you to my office, it is hampering your ability to direct the course of your own life. So let’s name your pain and then do something about it. Tell off the boss, walk out on the husband, confront the perpetrator, whatever it takes, and then move on, become the agent of your existence.

It’s a profession that has been good to me, and I hope good for my patients. But what if the premise is undone by circumstance? What if it turns out that we are hapless victims of a force arrayed against us, that will mercilessly hijack the machinery of our lives, that is silent and invisible and leaves us with nothing to do but cower in our homes and wash our hands and hope that it will pass us by? Is there a role for therapy in a pandemic?

Those are not the kind of questions I used to start my work day with, unless my first patient was someone with paranoid delusions. But then again, until a month or so ago, I didn’t start my working day by sitting down in front of my computer and clicking a patient into view. I’m already getting accustomed to it; the human capacity for adapting is remarkable. But the one thing I can’t get used to, so far anyway, is the way my patients’ faces appear in this simulacrum of intimacy. I may have sat for hours with them, watched their faces contort in anguish, or beam in satisfaction. I may have searched out their eyes, tried to bring them back into contact from their safe haven on the ceiling. I may have thought I knew every inch of these faces, and no longer even needed to ask what their expressions meant.

I wasn’t wrong, not exactly. I just didn’t realise that all that searching was done against so many tempting distractions: the catalpa trees outside my window, the paintings on my wall, the little corner of ceiling tile that was chipped 30 years ago and has never been repaired. I could swivel in my chair, adjust my posture, look at the clock, and then back to the face. Now that it has been reduced to a flat image in the middle of a flat screen, and I have no easy elsewhere to look, I’m realising that half the work was the struggle to behold those faces, and half the satisfaction was succeeding in wrestling attention to the task at hand. And maybe half the treatment was their observing that struggle, feeling the love in it.

Of course, there’s more to the video than just the face, and distractions aplenty on the screen. But they are unfamiliar to me, and not in the world I share with my patient. Take this patient, just a guy trying to figure out his life now that his wife has left him. I might have known all about his sex life and his financial woes, but not that his couch was brown and his living room painted sky blue. It feels a little indecent to be seeing it. It’s one thing to penetrate the hidden meaning of his words – after all, that’s what he’s paying me for – and quite another to catch a glimpse of something I’m only seeing because that’s where the best wifi is. Can I ask him what it means that the shelves above the couch are empty? Would that question be a sign of love, or just impertinence?

But still, that face. It’s right there. I can’t escape it, as I imagine he can’t escape mine. I keep looking at the postage-stamp version of what he is seeing. It’s vanity that draws my attention back to that corner of my screen, but it’s also curiosity. This hard and wrinkled face, this half-smile, these hooded eyes: this is what my patient sees? So much of my job is making sure I understand what I am conveying, labouring to launch my words across the room with the right inflection, the right expression, the one that carries my concern as well as my scepticism, that challenges and supports in equal measure, and watching myself watching myself, I can see that I haven’t got the slightest idea of how I am coming across – and I am far too interested in finding out. I click off the view of my own face.

So we are focused on each other’s faces, but there is still at least one thing missing: that moment when your mutual darting attention comes to rest and you make real eye contact, not the off-kilter kind that comes from peering at a screen located a few inches from a camera, but an actual meeting of actual eyes transmitted through the air of a shared room. You look into each other, and you see, even if you don’t say it out loud (and you rarely do) just how rare and precious this is, this intimacy that you have kindled by agreeing (and again mostly without saying so) to be honest with each other, and to sit with the consequences. Which is the whole point, the reason they pay and I work, and the means, if there is one, of healing, if there is any.

God, I miss that.

If anything unites the disparate branches of psychotherapy, it is the belief that trauma twists the timber of the self, and determines the precise shape of our suffering. Freud identified this as the “repetition compulsion”, the unconscious tendency to place ourselves in situations that are versions of the past – or to construe them that way. Some traumas are more obvious than others, outright violation easier to identify than the diffuse ineptitude of some parents, or their inability to provide both love and sustenance on a sales assistant’s salary, or the manifold humiliations children suffer at the hands of other children. But as capable as we might be at burying them, our traumas are more capable of haunting us. Therapy is the work of exhuming them, bringing them to light, and then putting them behind us.

This idea that the pain of the past shapes our present experience has never been scientifically proven, but it is very likely that this idea is part of how you understand your own history, whether or not you ever enter into therapy. And if you do come into my office, we will ferret out the trauma at the source of your discontent, and, having found it, if our work is successful, you will recognise it as the moment that turned your life, and as the moment that you must leave behind.

But what if the trauma is not hidden in the mists of time, but right here, in the midst of life? What if it grows at every moment, in every encounter, at no one’s hand in particular but at everyone’s hands – especially if they were unwashed and touched the apple that you are right now hesitating over in the supermarket. Maybe that guy on the other side of the apple bin is smiling at you, understanding exactly what you are thinking, or maybe he’s glaring at you, trying urgently to dissuade you from putting the apple back into the pile. You can’t tell, of course, because, like you, he is wearing a mask. And the only thing worse are the people who are not – the people who, encouraged by a president with a Jack-o’-lantern smile, believe that the cure is worse than the disease and have brought their entire families to the grocery store to escape their lockdown. Complain to me right now, in the middle of this video therapy session, about that president or the masks or the guy who touched the apple and put it back, and am I really going to tell you that your outrage is about your father – even if, in some ineluctable way, it is?

Or maybe you work in a hospital emergency department and you come home from your shift every day and take your clothes off in the garage and shower in the basement before joining your family upstairs, and you’re trying to snuggle with your kids, but all you can think of is the intubation you did, in full hazmat kit, and all those virulent droplets the patient expelled as you slipped the tube down his throat? Or you work in a nursing home and your ex-wife won’t let you see your children, even at a distance, until this whole thing is over, which is when, exactly? Or you are stuck at home in a marriage that depended for its success, you are just finding out, on your not being stuck at home together. Shall we go down memory lane in search of the trauma that has you ricocheting between boredom and terror? Shall we dissect your emotions so that you can see just how neurotic your response is?

Sigmund Freud circa 1932. Photograph: Imagno/Getty Images

Freud promised his patients nothing more than the ability to trade in neurotic misery for common unhappiness. Still, he harboured some optimism, albeit a strange variety. He would surely have scoffed at Anne Frank’s assertion that in spite of everything, people are still good at heart, but he did believe we have a heart, and that it could be convinced to ache less, if only we could tell it the right story. That story would have to be realistic. It could not be the “nursemaid’s lullaby” of religion or the paranoid person’s account of a world out to get him. Its hero would be the stoic, who could accept the price he paid for the comforts of civilisation: the never-ending need to restrain his animal nature, and to never lose sight of the inescapability of nature’s red tooth and claw. It was a tall order, but Freud was convinced that we could accommodate ourselves to reality rather than pretending reality was other than what it is.

Freud placed his bet on the human, as the source of both suffering and balm. He didn’t reckon with a nemesis so indifferent as a virus, any more than he worried about a meteor crashing into the Earth or the sun suddenly being snuffed out. The nice thing about depravity is that we can imagine ways to suppress it, and even succeed, if fitfully, at doing so. It’s not clear yet if we are ingenious enough to do that with this virus, and even if we are, that outcome is a long way off. In the meantime, we are stuck with the imperative to restrain ourselves to a degree that Freud did not anticipate. At a time when we need each other badly, when we are under attack not by human nature but by nature itself, the best we can do to take care of one another is to stay away from one another. Even Freud at his most misanthropic never imagined that.

Perhaps this is not the time to ask “What would Sigmund do?”. He’s not much of a role model in normal times, let alone times like these. It’s certainly not what I am asking right now, as I prepare for another day in front of the unblinking camera. What I am asking is the same thing that manufacturers turning their assembly lines to ventilator production or retailers improvising kerbside services are asking: how can I put my experience, my knowledge, my talents – suddenly rendered irrelevant and impotent – to use in a new and unfamiliar world?

Some things are the same. People still complain about their wives and their kids and their bosses. They still have dreams, although it seems like a lot of them recently are about being trapped. They still well up with sadness or bite off their words in anger. They still look to me for support and guidance. They still laugh at my stupid jokes and tell me theirs. They still show up – although occasionally, if the appointment is in the evening, with a glass of wine. They still talk to me, answer my questions. They still pay me, if by online transfer.

It’s reassuring, this continuity. It may help to explain one of the differences I’ve noticed: the ease with which people who are frequently evasive or argumentative or, as Freud would put it, resistant, seem to have suddenly shed their ambivalence. The man who could not talk about being molested now wants to, the woman whose abandonment by her husband left her too humiliated to speak of it now speaks of nothing else; the couple who always showed up to the office five or 10 minutes late now sign into my virtual office five or 10 minutes early, and are perched eagerly on their sofa when I open my screen.

Is it possible that the screen creates just enough distance to provide a safety that my words and gestures cannot? Have we inadvertently found a sweet spot between the detachment of everyday life and the cloud chamber of face-to-face therapy? Or are people so sick and tired of being cooped up with family, or alone, that they are spilling over with the desire to talk to someone else at any opportunity?

I haven’t had time to interrogate this yet. I suppose if lockdown keeps up or gets more stringent, I will have to. Or maybe people will discover a new way to protect themselves from my intrusions, as the old forms of intimacy, the ones that require physical presence, recede into memory and the video version becomes the new normal. Perhaps Covid-19 has only accelerated a trend already under way.

But the immediate question is not for the patients, but for me: what exactly am I supposed to do when I slip on the headphones and turn on the camera and another person in the midst of this crisis comes into view? The gambit of therapy is that the therapist is a few steps ahead of the patient, like a caving veteran leading a novice into a cavern unfamiliar to both; he may not know the particulars, but his headlamp is a little brighter and he knows how to find his way around. But this cave is unfamiliar and my lamp is dim. I don’t even have a name yet for the strange admixture of emotion – fear and helplessness and disorientation and sadness and anger, in constantly shifting measure – that has taken hold in the last month or so, and that has become the new background of my life, too. I’m just as terrified as my patients are, maybe more so – and not just of drowning in Covid-19 or infecting my wife or losing my friends to disease. I’m as afraid of the aftermath as I am of the illness. Police are using helicopters to enforce social distancing. To those who defer to scientists and public health authorities, that may seem like a good idea. To those who crave power and who understand science well enough to know that this virus will be with us for a long time, it may seem like an opportunity.

So I do not know what I am supposed to do when confronted with those worried, perplexed faces. I am making this up as I go along. I’m making more jokes than usual. I’m talking about my life more than I normally would, maybe because my patients hear my dogs barking or see the piano that sits in view of my camera as inexplicably as those empty shelves. And I am finding myself saying words I don’t remember saying, at least not so often: “Extraordinary times”, “unprecedented stress”, “uncharted waters”. To the man who can’t sleep, to the woman so racked by anxiety that she has begun to pull out her own hair, to the miserable college student whose postgraduate plans have evaporated along with the economy, to the parents of the high schooler who suddenly believes that the furniture in the house in which he is trapped is alive, and who, in less extraordinary times, probably would not have become psychotic, “I’m so sorry” is all I seem to have to offer.

These are not the circumstances for which therapy is designed. The events that bring us into therapy generally have the decency to be limited in time and place. A global pandemic is global, and it may never fully recede, or it may be replaced by another, and either way, we will have learned what few people alive today know firsthand: that, despite our dams and cities, despite our weather forecasts, despite our medicines and ventilators, despite the vast knowledge and dedication of our scientists, the genius of our artists, and the scale of our achievements – despite everything we have built to keep ourselves safe, we are not. We can be undone – not only by one another, but by a strand of proteins, and not only in a moment, but with months of warning and over more months, perhaps years, of fear and illness. The horizons on which nuclear holocaust or global warming are gathering are just distant enough to remain abstract, and they are at least theoretically under human control. Not so with a virus.

Therapists knew this long before Covid-19. Sit with people stunned by loss for any length of time and listen, really listen, to them, and it becomes clear that everyone will be confronted with grief and no one knows how it is supposed to go. So, if nothing else, we have got good at consolation. We know how to comfort, how to help people speak the unspeakable. Perhaps I will find use for other old tools, or the trauma of this pandemic will not prove as pervasive or persistent as it seems at this moment. But for the moment, this is what I have to offer those expectant, beautiful faces that are far away and so close: help in cataloguing the losses, and at grappling with them even as they mount. I can only hope it is sufficient.