First, I must start off with an apology for the delay and silence over the last few weeks. It has been a bit crazy as I am sure most of you can relate, and lately I have certainly felt like Eeyore. So, as we entered Level 2 of the lockdown, I felt this sense of relief. Maybe, just possibly this would give us just a chance to breathe, whilst still taking all the safety precautions into consideration and a hope that things were starting to change. It has been overwhelmingly crazy for all of us. I started to wonder if it was safe again…
The other day, I had a patient come to my practice, who was excessively pedantic about safety and wearing her mask, her face shield, sanitizing her hands, sitting exactly 2 metres apart etc. etc. and it made me start to wonder around safety and the meaning of it in the therapeutic space. She is an anxious patient already and her almost OCD tendencies around COVID-19 were her way of controlling her anxiety. However, this made me wonder how has COVID-19 impacted our therapeutic spaces and us, as therapists?
The therapeutic space is not meant to be one that creates a sense of unease and worry. Its fundamental purpose is to be a safe space for the patient. With the arrival of COVID-19, suddenly our environment and our therapeutic space has felt unsafe and difficult to engage with. It’s become mandatory to wear masks and I have most certainly noticed that the wearing of these masks has created anxiety as well as a feeling of unease, paranoia and just a general sense of not feeling safe. My interpretations of these masks, apart from the literal need to wear them, has varied from providing people some sense of control over a pandemic whereby most of us feel extremely helpless and out of control. They can also be used for a patient to hide behind, feel confined and imprisoned, shut off and closed off from the world. I have also noticed a considerable amount of trauma and loss being triggered by the pandemic, not necessarily entirely through the masks per se, but they are definitely a factor.
Sessions via ZOOM and/or Skype also seem to cause a certain amount of anxiety. We, as therapists, are now in the patient’s very vulnerable space of their home. I have been thinking about how to navigate this issue of safety and decided to put my Owl hat on and have a look at some research. Here are some of my thoughts and what the literature says:
Karen Horney believed that safety and security was more important than sex, which Freud believed. She felt that without these fundamental aspects hostility and anxiety can develop leading to fear, feelings of helplessness and loss of control. I have most certainly seen a rise in anxiety and anger during this pandemic and wonder about the innate need to feel safe and how the therapeutic environment impacts on this.Allison & Rossouw (2013) talk about the neuropsychotherapeutic perspective of safety and state that as humans, we have evolved to be able to feel connected to and safe to and with others.
“As humans, we have automatic responses to threats from other people or animals.” This is the fight, flight or freeze response. “This occurs when the amygdala (part of the brain’s anatomy that detects danger) signals the brainstem to inhibit movement.” Intense fear can limit our ability to move or even to think and reason. Thus the freeze response and “we are left with only our most basic responses, including tonic immobility, in which the body is literally paralyzed by fear. Similar reactions include collapsed immobility, which looks like playing dead, and dissociation, which is spacing out and feeling unreal.” I certainly have seen an increase in dissociative symptoms in my patients lately which not only impacts their sense of feeling safe, but also their relationships and ability to function in the workplace and at school.
Allison and Rossouw (2013) also talk about the Social Brain. As humans, we have a need for socialization and in order to meet this need our higher social brain is developed, also known as the ventral vagal complex (Porges, 2011). “Evolution led to a modified and more complex brainstem which is activated when we hear a soothing voice, see a smiling or relaxed face, and notice calm gestures. These signs became our social safety cues. They contribute to our ability to feel safe in close proximity to another person. We even become more able to listen to their words and to connect with them on an emotional level.” (Porges, 2011).
How can this assist us in feeling safe? According to Stephen Porges, we can give ourselves social safety cues. These may include pausing for a moment, distracting yourself from the stimulus potentially causing the distress, self-talk such as well as feeling compassion for the other person especially when that person is a partner, who is probably extra sensitive to our distress.
And therein lies the value of psychotherapy – to encourage the patient to be authentic in their fear, in their anxiety, for that creates in itself…safety.
Allison, K.L., & Rossouw, P.J., (2013). The therapeutic alliance: Exploring the concept of “safety” from a neuropsychotherapeutic perspective. International Journal of Neuropsychotherapy, 1(1), 21-29. http://nalandainstitute.org/2018/04/17/loves-brain-a-conversation-with-stephen-porges/
Porges, Stephen W. (2011). The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation. New York: W.W. Norton & Company.