17
RECLAIMING NEW HORIZONS:
THERAPIST OF 2020 PANDEMIC ERA
DR. PRERNA SHARMA
Clinical Psychologist, New Delhi
This article is the account of my personal journey - from working in a hospital as a clinical psychologist to the experience of working in the evolving reality of COVID-19 at various quarantine centers across Delhi. This also provides an overview of changing socio-cultural dynamics of the country in the light of COVID-19. This also further provides an insight into my internal changes and realizations that I had in my journey of discovering and witnessing new realities in the wake of the current pandemic. Lastly some new ways of relating to clients as a changed therapist post COVID-19.
The year 2020 began with new resolutions and plans. I chalked out my quarterly plan, half yearly and year-end targets that I planned to achieve in terms of research, conferences to attend, papers to be read there, new books to read, places to travel, new skills to learn and so on. The first quarter of the year seemed quite booked providing a sort of motivation and a boost to self-esteem. I had ticked a few boxes already by the end of January, 2020 and the world seemed to move at its usual pace, and me, faster. While rushing through my busy days at the hospital, I swiftly turned the pages of the newspaper one morning when I learnt of the first case of a novel coronavirus positive patient in Kerala (WHO, 2020). I thought to myself, well viruses have come and gone, we as a country have fought Ebola, Polio, H1N1 and so on. This also seems to be one of those with a different name and well, Kerala is far from Delhi. Being in my self-created world full of plans, I got a notice from the Health ministry that I will be posted in a quarantine camp set up at Indo-Tibetan Border Police (ITBP) facility nearly 30 kilometers away from where I reside. I thought to myself, “But what about my plans? I am an organizing member for a national level conference in February 2020, have to present papers, manage my clinical work, and have to let my clients know that I will meet them more frequently for a few weeks since I will be busier and unavailable for some time later.” This had come unplanned as per my schedule. With a little resentment and stress to manage this unexpected duty in an unfamiliar zone, I went ahead for the duty carrying my laptop, deciding that I will sit in a corner and continue working on my tasks. After all, what could be the need for a clinical psychologist in a quarantine camp! Quarantine! A word that I was getting acquainted with and would be making friends with in the coming months!
I drove through unfamiliar roads on the first day of the camp. As I entered the ITBP facility I saw soldiers wearing masks and holding their guns. As I reported to the chief medical officer, I got acquainted with the team. I learnt that there were doctors from All India Institute of Medical Sciences (AIIMS), ITBP forces, and virologists, scientists from National Centre for Disease Control (NCDC) all these institutes in Delhi. I was skeptical about my role. Nobody had a clue as to what my duty entailed since the whole team was busy preparing the facility as per the needs of the people and newly formed protocols. For now, I was curious to meet new people, interact and know more. After all, it was a break from my usual clinical duties and away from hospital! The ITBP in-charge of the facility showed me a building away from where we were standing which was cordoned off by tents around, guarded by soldiers. He told me that the building has 406 people from Wuhan who had returned home and were quarantined there. Till that time I didn’t know much about the virus and its mechanism and the NCDC people were helping us make protocols for everyone and the people inside. A wave of reality hit me suddenly when I saw the building and I wondered how people are “held” there with the knowledge that it’s for their safety. It’s human tendency that we tend to question the decisions made by others or even us, when it comes to questioning our freedom that we think we deserve. I wondered how so many people would be “okay” with staying in a closed unfamiliar place for 2 weeks with a possible threat of a harmful virus? My past resentment to deal with something unplanned in my schedule slowly faded away and I slowly came to my senses to the present reality. As clinical psychologists, we are also social scientists, which help us to predict intuitively due to innate skills which we develop over time by keenly observing human behavior. The quest of discovering this new human phenomenon began with curiosity and fear and I dropped all my guard. This intuition, influenced by all the social psychological theories, made me have questions like, what is the general environment like in a place where hundreds of people are confined in view of a threat to life. What are the psychological bearings on the minds of these people in view of a biological threat? How would a human mind react to an unfamiliar place and uncertainty? And after all what could be the role of a clinical psychologist here, when the real threat is purely biological in nature? And then began a journey where I wanted to investigate these as a researcher and a social scientist.
Curiosity replaces skepticism
On my second day I decided to talk to as many people as possible who were working closely and had seen it unfold from day one, to gather as much knowledge as possible. It was clear by now that I had to carve my own role and nobody had any clue as to how to use my services there. I got excited at the possibility of creating my own place here and doing my bit in creating awareness amongst these people who were providing “essential services” to them. A kind microbiologist from NCDC introduced me to PPE (Personal Protective Equipment) and trained me how to wear it. Interestingly I got to know that a lot of infections happened due to improper donning and doffing of the suit. Here was my first piece of knowledge that this virus will not harm a person who plays safe and takes all precautions. He took me to the facility and asked me if I was willing to take rounds on all the floors or talk to people with speakers stationed on each floor. By this time I wanted to know more. So I decided to go to each floor and meet as many people as possible to see what their living conditions were and how they were coping. As we went he explained the do’s and don’ts which reduced my apprehensions. I saw mostly young people who were staying in a dorm-type facility. To get a sense of possible psychological issues I interviewed a few people and observed others. Most people were experiencing anxiety being in an unfamiliar situation, unpreparedness on the individual’s part, apprehensions about COVID-19, sudden displacement from work or academics, being away from family, or loss of economic life. These situations were enough for the people to experience a range of mental health challenges depending upon one's vulnerabilities and the capacity to cope in a difficult situation. The human mind is designed to plan, predict and control future events with intelligence and previous knowledge, but being in an uncertain situation like this which they are not prepared for, is enough to create anxiety, experience destabilization and depletion of emotional resources.
Quarantine psychology
In the month of February in India, we did not have much news from other states about what the situation is likely to be in the immediate future. People who were managing the facility believed that these are the only potential carriers and if it is contained here then we are well managed. Since the situation did not seem out of hand at that time we felt that if we focus on this group and manage this, then we would have done a good job. The thought that if it becomes huge in the future, it would surely turn out to be a huge mental health crisis, did cross my mind often. However, the present scenario didn't make mental health seem like a priority. Nonetheless, I felt gratitude that I was present there to witness all that and offer help the moment it arises. It was not a surprise that I started getting calls from people for help. It was a social experiment of sorts which had started to play negatively on people’s minds. One person complained of getting over with his stock of cigarettes. On interviewing him I found that he has been a chronic smoker since 35 years and by no means was he willing to quit smoking which was helping him manage his stress. I was caught in a moral dilemma and I recalled the memoirs of Auschwitz prisoners who exchanged tokens which they had earned working on building railways, for cigarettes. Though it was an extreme analogy and no way comparable since these people were not prisoners, but they were prisoners in the hands of uncertain times and an unfamiliar place. I saw him getting more agitated each day and feeling the lack of freedom but I could not source cigarettes or write in his notes to allow him to smoke. My ethics were in question here. I tried doing behavioral intervention for urge surfing with him, but he was completely closed and only wanted the cigarettes. It was just a matter of days that demand for alcohol, cakes and non-vegetarian food started coming in from others. It was as if they were trying to trade off their anxiety and fear by getting these demands fulfilled. By this time, people started getting agitated and fighting within small groups. I started visiting these people almost daily. It was challenging to wear that suffocating PPE and not just talk to people, but to also form a sort of therapeutic alliance so that they could start opening up to my suggestions. All the non-verbal cues and soft skills of therapy like maintaining eye contact, sitting in proximity, using silence, or other micro skills were not of any use here. I had to be as verbal and clear as I could be. Most of the time it was diffusing the agitation and helping them calm down in my presence. Slowly the nursing staff, doctors on duty, and the mess staff started recognizing my efforts and need for psychological management. They would call me inside the building whenever the staff was not clear about how to handle and what to say to the people, especially the more agitated ones. I started briefing the staff on how to handle and what communication skills to use in order to calm their anxieties. By the end of two weeks of my quarantine stay I had challenged my boundaries and gained a lifetime experience. I had gratitude, prayer and compassion in my heart. I had grown from my own small self to a more open and kind person. So had my qualities that I needed to nourish as a clinical psychologist. I stood with the whole team on the fifteenth day when everyone was sent back to their homes in different states. I also happened to exchange some thoughts with the Health minister of the state and shared with him the fact that I was skeptical of the need for my services here initially, but that, at the end of the camp I had realized that mental health needed to be addressed along with the physical health and I thanked him to have thought about it as equally essential.
When pandemic teaches lessons
A month had passed and as I watched the news about the growing cases of COVID-19, I often wondered in utter dismay as to when and how it had turned into a national crisis. By this time the information was reaching at the speed of light and all of us helplessly witnessed the collapse of an ongoing system around the world. Gradually the cases picked up in India as they did the world over and COVID-19 was declared a pandemic. There were no other discussions happening within families, with friends and colleagues. We all started to adjust with the new situations each day, at home as well as work. ‘Pandemic’ and ‘epidemic’ became the most searched words on Google. Travel plans were shelved. Schools were shut. And a new reality that no one is immune to this threat had started to dawn upon the world. On 22nd March, 2020 a nationwide “Lockdown” was implemented. A new word was added to the day-to-day vocabulary and it became a topic of house-hold conversations. With newer words in our vocabulary and so much more information, I began the second phase of my duty at a different quarantine center. Despite my earlier experience, this time was not any easier. My previous knowledge did not make me feel confident, in fact it made me more apprehensive. We were all living a real and inevitable threat on the rise. It was my first day on the road after the lockdown and I found myself alone on one of the busiest highways in the country. I could not understand how to process it, it seemed like a scene from an apocalypse movie where the only sight was that of policemen barricading the roads with masks and gloves. As I entered the facility, I realized that the population was at a high risk since they were all elderly with medical co- morbidities and had come from abroad. There were 90 people in total and I decided to meet everyone and let them know that they can seek help anytime they need. As I started meeting them, I realized there were as many stories as there were people there. I met a family of 3 who were returning from abroad after completing the last rites of their young son who had died. They were bringing his ashes back to India. Then there was another lady who lived all alone in a small town in Haryana and was visiting her only daughter in another country. She had no one waiting for her at home after she was done with her quarantine stay. Each story had something different, something sensitive to make you feel small as a human. The stories were drenched with personal histories of trauma, displacement and uncertainty in the background of their age and vulnerabilities. This time was different for me since I learnt that there was a huge shortage of PPE and I could not afford to visit them every day. I offered my share of PPEs to the visiting doctors and nurses who needed it more and I offered my help telephonically. Every morning I drove on the lonely and quiet roads and I would sit at the reception waiting for my phone to ring in case anyone needed to talk. It was one of the loneliest times I had spent in my life. Each day I was learning about new, not so happy developments in the country. The system that holds everything together seemed to crumble in front of my eyes. Shortage of equipment became huge, doctors were seen exhausted, kits were not available to test frequently and lockdown had started to play on everyone’s psyche. I feared coming back home to a small kid and elderly parents.
A few days later, when I was trying to fit into the new normal for me, I saw hundreds of men, women and children walking on the highway. I wondered what could be the reason for this mobility. I stopped my car in curiosity and asked them where they were going? And they answered “home” . It just struck me that the migrant labour force had waited long enough and when things seemed hopeless for them they decided to go back to their original homes in search of safety. I realized this virus had not only threatened us biologically but seeped into the political, economic and social systems of nations, where marginalized people were bound to feel even more isolated and targeted. It was just a matter of days that the migrant crisis was known to all of us and some of us were moved to hear stories of hunger, homelessness and desperation.
As clinical psychologists it’s imperative that we understand an individual’s life story woven by cultural, political, social, economical, and religious threads, to name a few. Genesis of any mental illness lies deep in these aspects of life. All these aspects give us a unique identity and history that we identify with and relate to vis-à-vis others. When the system fails, the poor of the country are hit the most since they are more vulnerable. The mental health knowledge around migration and culture, displacement, trauma that I gathered over the years came to surface and compelled me to identify in reality around me. The mental health crisis is here, I thought to myself. This crisis is not confined to the fear and apprehension around COVID-19 but the repercussions it has on the social systems of the country. Pandemic has caused another pandemic! And as the theories of altruism and bystander’s phenomenon are conceptualized in books that I recalled from my masters, I witnessed there were people who came forward to help them, stepping out of their safety zones while for some it was pure apathy.
Our personalities often behave differently in crisis and that is what happens if we notice individual responses around us. One day, as I stepped inside the facility I got an SOS call from the staff that a guest from the US, living in the hotel had harmed himself badly and they had no clue how to help him out. Since they knew I was stationed at that hotel for quarantined people they reached out to me and asked me if I could attend someone out of the way of my duty. I quickly responded without thinking if I am stepping out of my jurisdiction and role to help him out. But in that moment it was all irrelevant and as I went up to his room I found him in a pool of blood. The hotel staff had provided him first-aid and was in talks with the embassy to manage him, since no hospital was ready to take him for admission on account of self-harm and being a foreign national in times of the COVID-19 threat. What followed between him and me is confidential, but I cannot help but mention here that an existential crisis can cause extreme anxiety, hopelessness and meaninglessness in life. A situation like this COVID-19 pandemic could trigger all past traumas and vulnerabilities that lie buried in many, at different points of life. Uncertain times like these have a huge potential to destabilize the system within us which tricks into believing that “all is well” because we as social beings are busy with work, family, travel, shopping, consuming and spending, and that starts defining and giving us a meaning in life. When everything is paused we don’t know what to do with our lives, our time and how to identify ourselves, hence the existential crisis.
Processing of an existential crisis
When Viktor Frankl (1984) was confined in concentration camps he observed that people who have found meaning in any form would be more resilient to face the tragedy because their immunities supported them to fight and look on the other side of the suffering. And as he said “Everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way.” The people who chose hope in the deepest pain and something to hold on to; survive. The situation that we find ourselves in may be unique to us and no one could be empathetic enough to know exactly how it feels to be “me” but, we may choose to “Live as if you were living a second time, and as though you had acted wrongly the first time” Frankl, (1984). We find ourselves discovering some real hidden potential that propels us to survive calamities or tragedies.
According to trauma therapists, trauma is not something that happens to us but our ability to exceed our coping resources especially in absence of an empathetic witness. While we see people responding to this who find coping through cooking, cleaning, meditating, finding new hobbies and attending more webinars, we also need to be mindful of the people who are struggling in their own unique way, responding to the challenges in the most primal ways they know. While we are careful of our correct processing of the whole situation, it is important that we provide empathy to others in order to reduce their trauma as well. By making such a stringent system where India witnesses tight lockdown in the country it is important that we are mindful of not creating stigma for those who are stepping out to care for us, and even for those who are infected. I cannot help but contemplate the reasons why a COVID-19 positive person commits suicide. There have been lots of such cases reported in the news across the country. Though it needs much deliberation and action, I could think of stigma, ostracism, uncertainty, isolation, disclosure of identity by police or authorities in their neighborhood that could cause shame and anxiety leading to suicide. It’s a flight response in the wake of intense trauma.
Self-reflections
As I am writing this and hear the news of “unlock 1” announced by the Government of India, I wonder where we go from here. Do we hold on to our old values or reframe new ones? Do we learn to hold space for others and be their ally even if it is by maintaining physical distancing? Do we become more mindful of how we live our lives and the choices we make? And above all do we move ahead processing this collective trauma by cultivating kindness, humility and valuing quality over toxic productivity. As Frankl (1984) said, “Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom”. As a therapist, I am learning to explore beyond my four-walled clinic where people come to me. I am learning new ethics on how to connect with people by making technology my ally rather than going by the traditional way of therapy (Manickam, 2020). I am learning to appreciate the contextual importance of a life story. I am learning to gain more skills on trauma informed therapy and incorporate it in my practice henceforth and above all as I am witnessing this in real time I am careful to process it with self-compassion and humility so I have the tools to teach my future clients as well as my child how to deal with uncertainties.
Suggestions for my fellow psychologists
The collective trauma that we have witnessed as humanity will claim a huge space in the collective unconsciousness. We will be talking about it to our future generations. There will be lessons learnt at individual, societal, national and universal level. There is no way we are going back to the same life as we knew it. We are discovering new ways of relating with ourselves and the world. We are going to make different choices hopefully which are more responsible as if we got healed through a trauma. Life changing events like this pandemic or Amphan cyclone or bush fires of Australia, or racial attacks in the USA or the current political climate of India in the recent past have lifelong bearings on the human psyche. They may pass as events, but the memory of the same is powerful enough to trigger the vulnerabilities in us. As clinical psychologists or citizens of the world we need to feel the responsibility and our role in these changes and realize the interconnectedness of human life. Only then can we understand a life story of a client in the post pandemic era from the viewpoint of all the psycho social systems. I will never forget that I share the same history of this pandemic with all my future clients. This interconnectedness and relatedness will take us from a trauma history to a healing future.
References:
Frankl, V. E. (1984). Man's search for meaning: An introduction to logo therapy. New York: Simon & Schuster.
Manickam, L.S.S. (2020). COVID-19 Pandemic: A time for prudent and ethical action. In L. S. S. Manickam (Ed.), COVID-19 pandemic: Challenges and responses of psychologists from India (pp.218-228). Thiruvananthapuram: The Editor.
WHO (2020). India Situation Report. https://archive.org/details/whocovid19-indiareport1.