To say 2020 was an unusual year would be an understatement. As a collective human society, we have all experienced significant changes in our once normal lives. One factor, COVID-19, has played the predominant role in this process, and some people have been more affected than others.
My personal experience with COVID-19 has led me to write this article so that my advisors have guidelines for helping other COVID-19 survivors. It is important to note that no evidence-based therapy practices are currently available as the pandemic continues to evolve. Before that, we hadn't seen a global pandemic in 100 years.
What is existential-humanistic psychotherapy?
Existential humanistic psychotherapy helps clients to discover their own uniqueness by gaining a greater awareness of themselves and the world around them. The therapist assists clients by teaching them to recognize their resistance so that they can have a more meaningful existence. Customers are free to explore which aspects of their lives support their journey and which can be discarded for a fuller existence. This approach avoids labeling and diagnosing so that focus can be placed on self-seeking and meaning.
There are five main goals in existential humanistic psychotherapy.
Develop self-awareness and understanding of the implications of freedom of choice
Create a personal identity and be present for quality relationships
Search for meaning, purpose, values and beliefs in life
Accept normal fear as a natural condition of life
Become aware of death and non-existence
Where do I start?
The COVID-19 symptomology and experience are unique to each individual. It is therefore important for existential humanistic psychotherapists to grasp a number of characteristics.
The therapeutic alliance must be established on the first visit. By entering into an I-Thou relationship with the client, you are first establishing a relationship in which the client is the authority on their personal illness experience and life. Second, your acceptance and support through unconditional positive consideration gives the customer the important opportunity to share and reflect on their subjective experiences. Third, by using empathy, you give your client the freedom to share a wider range of feelings and emotions with you, creating a space to deepen their authenticity.
Stages for the COVID-19 exploration
Stage One: Life Before COVID-19. This is an excellent entry point to begin the I-Thou therapy relationship. The client will begin to understand your existential humanistic style.
At the same time, you have the important opportunity to explore your customer's communication style and expressiveness. You will gain an understanding of the typical lifestyle, level of function and the values and beliefs of your customers before the COVID-19 pandemic. In addition, you can set the client's goals and what they want to achieve during therapy.
Questions that may be helpful could be:
Who did you live with?
What was your typical day
Have you been actively busy? How important was your job to you?
How did you spend your free time?
How was your general health?
Did you take your time
What was your "normal" one?
What did you appreciate most back then?
My normal lived with my husband and my son. My husband had had cancer treatment in another country for six months the previous year, and we were finally able to live together again. I worked in an advisory capacity. We usually spent our free time with family and friends, traveling and enjoying our personal hobbies.
Stage Two: Understand the client's early illness. In this phase, each customer remembers their unique symptomology and experience and shares them. At this point, your client may be more comfortable in the therapeutic relationship as you engage in active listening and empathic techniques. You will teach the client to examine their problem in order to develop insights by sharing physiological and psychological feelings related to their early illness.
Questions that may be helpful could be:
How did the disease manifest itself?
What were your early symptoms?
Where did you come into contact with the disease?
When did you find out that you were seriously ill?
What steps have you taken to address your illness?
What did you think and feel about your symptoms?
What were your concerns at the time?
My symptoms – dizziness, cough, increased sense of smell, kidney pain, and extreme fatigue – started in late March. My doctor prescribed an antibiotic for me and suggested avoiding the emergency room as all internal patients were believed to be positive for COVID-19 at this point and if I didn't have COVID-19 I would surely acquire it upon my arrival . (It was days later when I understood their logic).
So I spent a few days in bed and slept most of the time. I made every attempt to avoid the kitchen because I was overwhelmed by the cooking smells. I had a desire to indulge in very hot baths, but each one seemed to make me weaker than the previous one. At that point I felt insecure because I didn't have work. I was also afraid that things would get worse.
Stage three: Determination of the client's degree of illness. At this stage a more serious illness is recognized, the symptoms worsen and finally a higher level of care is required. Ideally, your client will be able to express a wider range of feelings and thoughts when revealing how they have dealt with their level of illness. As a therapist, you can begin to introduce the concept of freedom of choice into your decision-making.
Questions that may be helpful could be:
How long have you been sick?
What were your worsening symptoms at that point?
Why did you choose additional care?
How did you find out that you actually had COVID-19?
How long have you been in the hospital?
What did you think and feel when you realized what happened?
What were your concerns at the time?
As part of four days of deepening symptoms, I stopped eating and drinking. I couldn't consume anything mainly due to my increased odor symptoms. At the same time, I began an insidious decline in my ability to oxygenate my lungs, and so I eventually let my husband take me for the inevitable drive to the emergency room.
We were met outside the hospital by front line health workers in full personal protective equipment. My husband had to leave before I could go to the emergency room. In those early days of the pandemic, when only a limited number of cases were discussed in the media, the severity of the illness was not yet widely known, but the chances were I would never see my husband again. Although we had both experienced the fear and sadness that my husband had gone to cancer tests and eventually diagnosed last year, we both knew naturally that my departure was different from anything else we had experienced before.
Fourth phase: What experiences did the client have during his care? While this phase deals with the physiological happenings with the client, it also brings out some key existential concepts for early research. As COVID-19 patients spend time in the required isolation intensive care unit, fear increases and universal issues such as freedom of choice, isolation, insignificance, and death are carried over to them and become inevitable.
First, the meaning of illness itself is examined, while one has to deal with the task of control. Second, one finds meaning in the loneliness they experience. Some clients may find that this is the first time in their life that they have been alone or have had the opportunity to focus solely on themselves. Third, it makes sense in the emptiness of its surroundings. Fourth, it is about finding meaning in life itself and dealing with possible death.
You (as a therapist) can openly discuss the reality of death at this stage. Active listening and unconditional positive consideration are of the utmost importance in this phase as this is where the transformation finally begins. The client deserves complete freedom to share all of their thoughts, memories, and feelings, no matter how irrational they may seem to you.
Questions that may be helpful could be:
Do you understand what happened medically?
What were your feelings during early care?
Was this your first experience with emergency care?
How did you feel when you realized you needed to give full control to the medical staff?
What treatments did you receive?
Did you need to use a ventilator?
How long was your stay?
What emotions and feelings came into play? Were you scared? Bored?
How did you feel all alone?
What did you think and feel when you realized what happened?
What were your concerns at the time?
Did you think you would die
How did you deal with that thought?
Did you draw any conclusions?
During my first career, I spent many years on the front lines as a health worker. So I went back to my roots in the hospital and was fully aware of what was happening. With this in mind, too much knowledge can also prove frightening. I was quickly made aware of the gravity of the situation and realized that the best approach was to give up control immediately so that staff could make every effort to save my life.
I spent the next two weeks in the intensive care unit and continuously received 15 different drugs, mostly intravenous, and 24-hour oxygen therapy, as well as many venous blood and several arterial gas tests and portable chest x-rays. My oxygen levels were very low and did not respond to treatment.
I had long since realized that I would not have any visitors and that death was a possibility. My whole focus was on one thing: breathing in and out repeatedly, even when COVID-19 was playing pranks to convince me not to breathe anymore. A ventilator was considered, but I knew there would be an 85% chance of never breathing alone again. Each labored breath represented many things – avoiding the ventilator, returning to the presence of my husband and son, lying in my own comfortable bed, and not dying alone.
Despite my desire to return home, I spent many hours in the intensive care unit reflecting on my life and the possibility of death. I reconciled my life with God and was in a place of total peace. I have come to terms with all the relationships in my life and feel sorry for the people who have not been able to make a real connection. I was extremely grateful for what has been made available to me in my entire life, including my family, special friendships, and the ability to connect with others.
Fifth stage: healing and meaning after hospitalization. Checking out of the hospital gave me great hope. I had achieved what I set out to do there. At this point, I still had oxygen for 24 hours a day and was able to walk about 24 feet before exhaustion set it. With little information available, the doctors had to quarantine me for another week and then another week. I came to realize that all one can do for the sick or the terminally ill is to provide food and let the person know that they are loved.
Two weeks alone in my bedroom and my perspective had changed again. My wonderful bed had become my new prison. But eventually I was released from isolation and was able to experience smiles, laughter, human touch, hugs and togetherness again.
Level six: where do we go from here? Certain clients will benefit from cognitive behavioral therapy at this point in time to investigate possible biases who are satisfied with their progress and thus end their therapy at this point in time.
Others given the opportunity to begin their personal COVID-19 journey will open up opportunities for the future. First of all, you can investigate the fear with the customer. You can offer psychoeducation to help the client understand the purpose of fear and differentiate between existential, normal, and neurotic fear. You can then examine how freedom of choice is used in decision making and relates to the future, and discuss the reality of death in more detail. The introduction of Maslow's hierarchy and self-actualization can provide psychoeducation for the client to build self-awareness in the present and provide a roadmap for the future.
Questions for a possible exploration can include the following:
Do you see yourself differently since your illness?
What did you learn about yourself
Do you feel more comfortable at this point?
Have your values or beliefs changed in any way?
Have your thoughts or fears about death changed?
Are there any changes you would like to make in your life?
How would you like to spend your time in the future?
Will you handle situations differently?
Persistent COVID-19 symptoms, including bouts of low energy, occasional low oxygen levels, and the unfortunate loss of a lot of hair, still plague me. However, they are insignificant compared to my desire to help restore COVID-19 survivors and frontline workers who find meaning in their personal experiences.
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I want to thank Ayala Winer and Arlene Gordon for their gentle guidance in encouraging me to share my story.
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Audrey Karabiyik is a graduate of Nova Southeastern University and is currently a registered Florida mental health intern. She founds several COVID-19 groups aimed at survivors, frontline workers and others who want to deal with the "new normal". It is affiliated with the Systemic Solutions Counseling Center in Plantation, Florida. Contact her at [email protected].
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It should not be assumed that opinions or statements in articles appearing on CT Online represent the opinions of the editors or guidelines of the American Counseling Association.
