Treating Psychotherapy Patients in the Era of Coronavirus

As I write this, human beings are in the midst of mobilizing public health and psychological defenses against what will most likely be declared a pandemic by the World Health Organization this week. WHO and the CDC as well as state and local governments have issued guidelines, countries have begun self-quarantine, and as I write this Harvard just made the decision to move to virtual classes until further notice.

On a interpersonal and sociological level, we have begun to see the signs of adjustment reaction in conversations with others and on social media. The Nieman Foundation for Journalism has a page on Covering Pandemics which is very salient to us all in explaining adjustment reaction. It refers to the ways people attempt to recalibrate themselves psychologically during such traumatic and disruptive events, vacillating between overreaction and underreaction, minimizing and denial vs panic in their attempts to master confusion and anxiety in ways both adaptive and maladaptive. Perhaps you have noticed that (to paraphrase a comic I saw this week) all of your friends on Facebook who were constitutional scholars last month are now epidemiologists.

Recently I was seeing a longterm patient of mine, I’ll call her Randi*. Randi is 65, and began seeing me 10 years ago for help with dual diagnosis addiction and major depression. She also has a chronic pulmonary condition. I’ve been seeing her online for the past several years, most recently from her home in Costa Rica. This session was full of uncertainty and questions: She was scheduled to return to the US to renew her visa, should she come? Should she be holding hands at AA meetings? Should she be attending them? She has begun to follow the CDC recommendation of social distancing, and was worried about the impact of this on her mental health.

The guidelines we are being issued by public agencies are as clear as they can be during a time where data is still changing and community responses are fluctuating. At this time several suggestions are consistent from the CDC and can be found here.

As clinicians it is not our responsibility to learn epidemiology or get a degree in public health. However, we have a very important part to play in addressing the mental health issues that will accompany and/or be exacerbated by COVID19. I am listing the ones I have seen emerging in the hopes that we can help provide ancillary support for the mental health and behavioral health of our patients. If you are a therapist, please consider these. If you are a lay person, these are for you too.

  1. Reality-testing requires research. One of the main goals a therapist provides to the patient is supporting accurate reality testing. As mentioned above, reaction adjustment impacts our reality testing. Patients may present minimizing or panicking. To intervene, we need to know what the research as it is current says. Currently the mortality rate is 3.4% so yes, it is more lethal than the flu. We also do not know how this figure will change when more people are tested. But that is what we know. So the therapist needs to model both an not-knowing stance and assert what is currently known. This includes implicit communications (hand sanitizer in waiting room, offering teleheath sessions) as well as explicit ones (confronting extreme statements on either end, sharing what you know and verifying the source of your information.) Keeping abreast of the research allows you to help patients who are in higher risk populations shift their thinking and behavior to the new situation, while reassuring patients in lower risk populations understand their risk. Pointing out overreacting and under-reacting requires us to know what it is possible to know at this time, as well as manage our own countertransference response as we go through our own period of adjustment reaction. As this is all in flux be prepared to have discussions that are in flux.
  2. Address the needs that public health agencies aren’t in regards to social distancing. While it is becoming clear that more people are being advised to practice social distancing, the impacts of that on mental health are not being adequately discussed. This is absolutely understandable as the primary goal of public health in is to reduce infections to increase population survival. But helping the individual person-in-the-environment is where we come in as therapists. We know the importance of decreasing isolation for good mental health. We need to anticipate an increase in depressive symptoms, anxiety, and substance relapse may occur if the psychological impact of isolation is not addressed. We will need to help patients explore how to renegotiate boundaries as they rethink whether to hold hands at an AA meeting or a second date. We will need to help people shift to online therapy and self-help groups rather than avoid them. Social connection will need to be more planned and intentional, more technologically dependent for many. We may need to assert that immunocompromised individuals stay out of our physical offices for their safety, and explore the feelings this evokes for them.
  3. Support patients in preparation for managing their psychopharmacological needs. Help them anticipate pharmacy delays and encourage them to follow the recommendation that they get 2 months worth of prescriptions whenever possible. Be prepared to offer more case management with them as they negotiate resistance with health insurance companies.
  4. Confront and redirect the inadvertent demonization of touch. This one is huge. This past week many have become acutely aware of how often they touch their face, or others without asking permission. To control the spread of infection this is crucial, and yet we need to also resist the urge to begin to perceive touch as unnecessary or lethal. Touch and reaching is a part of healthy infant development (Beebee, 2016.) It plays a significant role in focusing attention and attachment security in adolescence (Ito-Jager, 2017.) Children need to touch themselves as part of learning motor imagery (Conson, 2011) body ownership (Hara, 2015) and the assembly of “self” (Salomon, 2017.) Research has shown that adolescents in America already touch each other less and are more aggressive to peers than in another country sampled (Field, 1999); and for all of us touch quite probably helps us with emotional self-regulation (Grunwald, 2014.) Self-touch is a cornerstone of mindfulness and compassion meditation practices. Therapists need to help patients and their families practice everyday precautions while at the same time reminding them of the necessity of touch for basic neurological and psychological well-being. We need to anticipate that we may be asking people to do something which conflicts with adaptive self-soothing responses to distress. We may be unintentionally causing a reenactment of a trauma survivor’s bodily domination by the abuser when we start telling her what she can and cannot do with her body. We may be taking away a kid with ADHD’s main way of focusing. So the goal of therapy becomes the reduction of shame and irrational demonization of touch, and the development of adaptive ways to continue giving ourselves touch so we do not become a planetwide Harlow monkey experiment.
  5. Last but not least, hold the therapeutic frame. The majority of our patients were working on things in therapy before the events of the past two weeks. I have asked each in the last portion of the session “what do you imagine you would have been talking about in therapy if you hadn’t been discussing the coronavirus.” In the case of Randi, that question prompted her to remember that someone had attempted to break into the apartment where she lived alone, itself a pretty distressing event! Another patient, a 30 year-old male with Dysthymia, had made two major and difficult behavioral changes that week, a success that would have been crowded out by COVID-19 if we hadn’t paused to discuss earlier events. We need to keep an eye on the ongoing work, how the patient’s neurotic styles vis a vis pandemics are often in keeping with their style overall,and what other events have occurred in their week.

These are some of the most important “new” responsibilities I see us having as therapists when dealing with the emerging coronavirus crisis. I imagine more will be revealed, and I imagine that at some indeterminate time in the future it will become more clear what the psychological impacts of adjustment reaction, social distancing and touch aversion had on human development. In the meantime, please consider sharing this with your colleagues and patients so that they do not lose sight of important impacts on their mental health caused by necessary public health precautions.

Such interventions and frame maintenance model an adaptive stance in that they are hopeful: That there is a lot of work to be done is always an expression of hope, never despair.

*patient identification changed to protect privacy


Beebe, B., Messinger, D., Bahrick, L. E., Margolis, A., Buck, K. A., & Chen, H. (2016). A Systems View of Mother–Infant Face-to-Face Communication. Developmental Psychology, 52(4), 556–571.

Conson, M., Mazzarella, E., & Trojano, L. (2011). Self-touch affects motor imagery: a study on posture interference effect. Experimental Brain Research, 215(2), 115–122.
Field, T. (1999). American adolescents touch each other less and are more aggressive toward their peers as compared with French adolescents. Adolescence, 34(136), 753–758.

Grunwald, M., Weiss, T., Mueller, S., & Rall, L. (2014). EEG changes caused by spontaneous facial self-touch may represent emotion regulating processes and working memory maintenance. Brain Research, 1557, 111–126.

Hara, M., Pozeg, P., Rognini, G., Higuchi, T., Fukuhara, K., Yamamoto, A., Higuchi, T., Blanke, O., & Salomon, R. (2015). Voluntary self-touch increases body ownership.(Brief article)(Author abstract). Frontiers in Psychology, 6.

Ito-Jäger, S., Howard, A. R., Purvis, K. B., & Cross, D. R. (2017). Attention focus and self-touch in toddlers: The moderating effect of attachment security. Infant Behavior and Development, 48(Pt B), 114–123.

Salomon, R. (2017). The Assembly of the Self from Sensory and Motor Foundations. Social Cognition, 35(2), 87–106.

Triscoli, C., Olausson, H., Sailer, U., Ignell, H., & Croy, I. (2013). CT-optimized skin stroking delivered by hand or robot is comparable. Frontiers in Behavioral Neuroscience.

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