Existential–Humanistic Therapy and Disaster Response: Lessons From the COVID-19 Pandemic

Abstract

The COVID-19 pandemic has dramatically affected the mental health field. The unique distress caused by the pandemic along with the need for many to transition their therapy practices to TeleHealth/Telepsychology modalities caught many therapists, including existential–humanistic therapists, unprepared to make the necessary adjustments to treat clients in a manner that is safe and effective. Existential–humanistic therapy often is neglected with trauma and disaster relief work, despite its relevancy and important contributions. All therapies must adjust in crisis situations, particularly when adjustments to how services are offered are disrupted; however, the impact of these changes varies by therapeutic orientation. As an approach that values genuineness, empathy, and presence, existential–humanistic therapy faces unique challenges when employed with disaster response. However, when these challenges are faced, existential–humanistic therapy has much to offer disaster response, including consideration of existential guilt, existential shattering, existential anxiety, and existential perspectives on self-care.

COVID-19 dramatically affected mental health practice as well as many aspects of society. Over the past couple of months, many health practitioners awoke to the rapidly changing context unprepared for the necessary adjustments needed to practice safely in the times of such crises. Crisis situations bring existential issues into critical focus, yet existential–humanistic perspectives often are left out of disaster response options.

For the past 13 years, I have worked with Mark Yang, Xuefu Wang, and other colleagues offering trainings on existential–humanistic and humanistic psychology in China. This work led to the establishment of the International Institute for Existential-Humanistic Psychology (IIEHP), which now offers systematic training in China (see Hsu et al., 2019; Thrash et al., 2019). This work began around the time of the 2008 Sichuan earthquake (see Dias & Ren, 2019; Ren et al., 2018; Ren et al., 2020), and was influenced by the disaster response efforts. When the COVID-19 crisis began to emerge in China, many individuals affiliated with IIEHP in China and the United States quickly volunteered to be part of the response efforts. My familiarity with using video conferencing and involvement in response efforts to COVID-19 in China prepared me for the issues that emerged in the United States and serve as a foundation for this article.

TeleHealth and Telepsychology

COVID-19 forced many therapists to quickly begin learning how to adapt therapy in a manner that prioritizes the safety of their clients and themselves. One positive outcome that may emerge from COVID-19 is that most therapists likely will have crisis and pandemic strategies in place to quickly adapt to similar situations in the future. Most likely, this will rely heavily on TeleHealth and Telepsychology. In a short period of time, the therapy landscape changed from TeleHealth and Telepsychology being relatively rare to where most therapists were using Telepsychology with their clients, even if only temporarily. Many therapists struggled to quickly immerse themselves in the legal, ethical, and practical issues of transitioning to Telepsychology.

TeleHealth is a broader term used in medical and psychological settings to refer to a variety of interventions including phone calls, email, text messages, the use of health and mental health apps, and other interventions employed through technological mediums. Perle et al. (2011) note that TeleHealth can be traced back to 1959 when it was first utilized through a closed-circuit television network by the University of Nebraska School of Medicine. It remained in relative obscurity for many years with the exception of some rural settings where clients had limited access to treatment, especially from specialists. In recent years, it has grown in popularity.

Telepsychology is one approach within the broader domain of TeleHealth. In 2013, the American Psychological Association’s Joint Task Force for the Development of Telepsychology Guidelines for Psychologists (2013) published “Guidelines for the Practice of Telepsychology” in the American Psychologist. In this article, Telepsychology is defined as “the provision of psychological services using telecommunication technologies” (p. 791). This includes, but is not limited to, providing therapy through HIPPA compliant video services. In recent years, many states introduced legislation specifically targeting mental health professionals practicing Telepsychology. Similarly, insurance companies have begun reimbursing for Telepsychology. A specific CPT code modifier (95), has been introduced for reimbursement for TeleHealth; however, some insurance companies still use different approaches to coding for TeleHealth.

While insurance companies were slow with beginning to pay for Telepsychology before COVID-19, most began opening up this option more widely as the pandemic spread. This may be temporary, but also may encourage insurance companies to make this a more readily available option after the pandemic. The acceptance of TeleHealth and Telepsychology has been more rapid with licensing as compared with reimbursement. Although varying from state to state, the standard practice has been that the therapist must be licensed in the state where the client is currently located in order to practice Telepsychology. However, the Association of State and Provincial Psychology Boards (ASPPB) began working on standards for practicing TeleHealth in psychology across state lines in 2015 (www.asppb.net). Their initiative, called PSYPACT, was to be enacted when seven states passed legislation approving PSYPACT, which occurred in 2019. As of the time of this article, 12 states have enacted PSYPACT legislation with another 16 states and the District of Columbia having pending legislation (https://www.asppb.net/mpage/legislative). However, ASPPB is still finalizing the Bylaws and Rules necessary prior to implementing PSYPACT.

TeleHealth and Telepsychology are poised to become essential components of mental health disaster plans in the future. It will be valuable for therapists to have foundational knowledge and basic skills for practicing Telepsychology, even if preferring to primarily practice face-to-face therapy. Additionally, it will be important for training programs to address foundational issues of Telepsychology.

Telepsychology is different than face-to-face therapy in many ways; however, there is limited research to clarify these differences. I have been practicing Telepsychology on a limited basis with clients and supervisees since 2017. However, following the COVID-19 pandemic, I temporarily shifted to doing this fulltime. My experience is that Telepsychology is more physically and emotionally tiring. In conversations with colleagues, this appears to be a common experience. Telepsychology may require different types of self-care to offset the unique impact of providing Telepsychology services. Therapists must have HIPPA compliant secure video systems with a signed Business Associates Agreement and adapt their informed consent or have an additional informed consent specifically for Telepsychology. Additional considerations include having appropriate technology available, having an Internet connection with adequate speed for video conferencing, having a backup plan for technology failures, having appropriate lighting and nondistracting backgrounds for the video, knowing how to coach clients less familiar with technology, knowing how to address client’s questions about Telepsychology, and learning how to attain appropriate resources local to the client in case of crisis situations. While there are a number of good guides to help therapists learn what is necessary to transition to Telepsychology, even if temporarily, there is a significant time commitment necessary to do the transition well.

In addition to developing the necessary knowledge and skills, therapists wanting to expand their services to help clients affected by pandemics and disasters will need to learn how to market their services in times of crisis or network with individuals that work directly with disaster response for referrals. This can come in various forms. With most disasters, it is ideal to begin with face-to-face crisis services as quickly after the disaster as possible (Ruzek, 2006). For therapists who provide these services, they may not be able to offer continuity of care, especially if their practice location is not close to the disaster location. It is important to address these limitations upfront with clients. Telepsychology is one option for providing continuity of care. In situations where there are insufficient mental health resources at the location, Telepsychology may be an option for supplementing face-to-face services, particularly for individuals not in active crisis. Triaging can help assure that individuals experiencing a mental health crisis are directed to face-to-face services, while guiding individuals in less distress to other options, such as Telepsychology. In the situation of a pandemic or disaster in a remote area, Telepsychology may be the only option for many individuals, even if less than ideal.

While all types of therapy are affected by shifting to Telepsychology, some approaches may be more significantly affected. Existential–humanistic therapists rely heavily on therapeutic presence, which is different when conducting therapy through video technologies. The therapist has a more limited view of the client due to the camera, which means a more limited range of nonverbals from which to draw as well as the loss of the felt energy in the room. If the client does not have adequate lighting or has a bright light behind them, it may be difficult to clearly see the client’s nonverbals. If the client or therapist do not have good quality cameras, microphones, and speakers, this, too, can limit the ability to clearly communicate, particularly some of subtleties that are important for existential–humanistic therapy.

After several years of practicing Telepsychology on a limited basis, my professional opinion is that Telepsychology is not ideal for existential–humanistic therapy. However, I also believe that it has its place. In addition to use during pandemics and crisis situations, Telepsychology can be useful for clients who may have physical issues preventing them from traveling, clients who move but would benefit from continuity of care, and clients who live in remote areas with limited access to therapy services. As there are many areas where there are no existential–humanistic therapists, it also provides access to this type of therapy for many individuals who otherwise may not be able to seek out existential–humanistic therapy.

Short-Term and Long-Term Strategies

Disaster work is filled with complexities that require mental health professionals to respond differently in various contexts and points in the timeline. For existential–humanistic therapists, it requires the use of integrative strategies (Schneider, 2008b, 2008c; Schneider & Krug, 2017) that allow the therapist to adjust the frame and intentions to the needs of the client. Short-term and long-term strategies may vary, stretching therapists’ ability to maintain a consistent frame. Ideally, strategies are put into place where the short-term and long-term strategies work together.

In many disaster situations, it is important to address trauma at the individual and community levels (Olweean, 2019) as well as considering other cultural differences. Often, disaster response includes teams that have traveled to locations to provide therapy. It is critical that therapists working with individuals from different cultural contexts function from a framework of cultural humility and seek to learn from local experts about how to adapt their therapy frame (see Hoffman et al., 2019). In international contexts, Yang and Hoffman (2019) advocate that cross-cultural work should include (a) cultural critique of approaches developed outside the context where it is being applied, (b) cultural adaptation, and (c) the incorporation of indigenous strategies. The critique, adaptation, and, in particular, the incorporation of indigenous approaches should be led by experts in the culture in which the therapy is being applied (i.e., when applying Western approaches in China, individuals from China should lead the critique, adaptation, and incorporation of indigenous Chinese approaches).

Short-Term Strategies

The immediate response to crisis situations necessitates short-term interventions, which many existential–humanistic therapists are averse to relying on. However, it is possible to implement these in a manner that is consistent with the depth psychology framework of existential–humanistic therapy (see Schneider, 2008a). The primary objection to many short-term interventions and techniques is that they focus on the symptoms and quick fixes rather than engaging the deeper being-level issues, such as learning to stay with one’s emotions, becoming curious about one’s emotions, and listening to the message of these emotions. However, clients who are overwhelmed by a crisis or trauma often cannot go into the deeper clinical work without some resources that provide confidence in one’s ability to manage emotions they perceive as overpowering.

It is important to distinguish between short-term interventions as an end to therapy versus short-term interventions as part of deeper work. While managing emotions and other symptoms is the goal of some approaches to therapy, in an existential–humanistic or existential–integrative framework, this is a starting point (Wolfe, 2008). Short-term interventions tend to focus on coping and skill development. While coping is necessary with many forms of psychological distress, to simply learn to cope falls short of the full potential of existential–humanistic therapy. When short-term interventions are implemented in the context of what Serlin et al. (2019) refer to as a whole-person approach, they become consistent with an existential–humanistic approach.

The Relational Frame

The relational frame with an existential–humanistic approach is embedded in presence (Krug, 2009). In describing presence, Krug (2019) states that, “Presence involves aspects of awareness, acceptance, availability, and expressiveness in both therapist and client. Presence implies that the encounter is real and that the client and therapist include each other in each other’s recognition” (p. 262). In disaster response, it can be easy to skip the relationship building to move on to crisis intervention techniques; however, this can be a mistake. The relationship still can provide a sense of safety and connection as well as serving to contain emotions. Furthermore, establishing a good relationship can be critical for long-term follow up. Clients who have a positive relational experience with a therapist or mental health professional in a crisis situation may be more likely to return to therapy after the crisis has passed.

From an existential–humanistic perspective, relationship can be utilized as a primary strategy to help clients cope. An individual’s relationship context following a disaster event or trauma plays a significant role in the individual’s experience and recovery (Hoffman & Whitmire, 2002; Stolorow & Atwood, 1992; Young, 2006). In considering this from a developmental perspective, infants and young children often turn to their parents or caregivers to help them calm down in times of distressing emotion. Healthy adults often continue to utilize these relational strategies by turning to others in times of emotional distress. In much of Western society, people are indoctrinated with individualism from an early age. Individualistic perspectives tend to emphasize that the individual should be able to manage or control their emotions on their own without reliance on others.

Many Western psychological approaches, particularly solution-focused therapies, tend to emphasize skills that a person can utilize on their own after learning how to use them. While these skills-based approaches can be valuable, they also can contribute to isolating people if they are interpreted as telling disaster victims that they should be able to manage their emotions on their own, or if they are not combined with more relational coping strategies. When working with trauma and disaster clients, my first emphasis is on using the relationship to help clients cope with emotions. For some clients, this is sufficient; however, many clients require additional coping strategies. The additional coping strategies often are more effective when implemented in the context of a good therapeutic relationship and when combined with relational strategies that address the feelings of isolation and being alone.

Framing Short-Term and Solution-Focused Interventions

Although often eschewed by existential–humanistic therapists, solution-focused interventions are, at times, essential in disaster and trauma response. However, existential–humanistic therapists may utilize these differently. For example, when introducing these techniques, I generally provide a framework for understanding coping skills and other solution-focused interventions, such as stating:

There are a variety of strategies we can discuss to help you cope with the intense emotions. In some approaches to therapy, learning these skills is the primary focus of therapy. I tend to approach this differently. Learning to manage and cope with strong emotions can help you gain a sense of control over them. As you become more confident in your ability to control your emotions, it becomes easier to be curious about what these emotions may be telling you and seek out deeper levels of change that address underlying issues. It is always up to you as to whether you want to focus on managing and coping with your emotions, or whether you want to continue working with deeper emotions and possible underlying challenges after you are more confident in your ability to manage your emotions.

There are several things that I am trying to accomplish in a statement such as this. First and foremost, I want to help the client recognize their agency. For the client to experience agency, they need to recognize that they have choices, which many clients often cannot see in the wake of a traumatic experience. The recognition of options and choice begin empowering the client. Second, I want them to be aware of the benefits of strategies that go beyond solution focused techniques and skill development. In the above statement, I am honest about my bias while highlighting that there are other options. I do not believe we help our clients by hiding such biases, particularly as they influence how we approach therapy with them. However, we may cause harm if we impose our biases on clients. Ideally, therapists help clients recognize options and empower them to make informed choices. At the outset of therapy, clients often do not have sufficient information to make informed choices about therapy.

Selecting Short-Term and Solution-Focused Interventions

Schneider’s (2008b, 2008c, 2016) existential–integrative model seeks theoretical and epistemological consistency. Differentiating from eclectic therapy approaches, most integrative strategies strive to first have a solid foundation (Hoffman, 2019). From this foundation, other therapy strategies can be integrated. To maintain theoretical consistency, it is important to assess whether other strategies fit with the foundation. When integrating with an existential–humanistic foundation, it is important to consider which strategies are consistent with its underlying philosophy and values. At times, strategies that are integrated require modification to fit with the existential–humanistic foundation as in the illustration above pertaining to integrating solution-focused strategies.

An example can help illustrate the importance of maintaining theoretical consistency. From an existential–humanistic perspective, anxiety, as well as other emotions, are essential guides to the therapy process (Hoffman, 2019; May, 1958, 1977). When focusing too tightly on managing or reducing emotions, the guide is lost. Furthermore, Watson et al. (2010), in their review of the research, provide evidence that tolerating moderate to high levels of emotions in the therapy room is predictive of better therapy outcomes. Clients may be able to tolerate these higher levels of emotions if they have some confidence in their ability to manage them, which provides support for an integrative approach in which clients are using some solution-focused strategies to build confidence in managing emotions while not seeking to over-control or eradicate them. Thus, through adapting how the solution-focused strategies are used they shift from being a poor fit with existential–humanistic therapy to being proficiently integrated in a manner consistent with the theoretical foundations of existential–humanistic therapy.

Short-Term and Solution-Focused Interventions

One approach that previously was more commonly used in the wake of trauma or disaster is critical incident stress debriefing; however, there is limited empirical support of its effectives and some research suggests this may retraumatize some clients (Friedman et al., 2006). Debriefing and similar strategies, if utilized, may be more effective as a long-term strategy, if used at all. As many existential–humanistic therapists have a strong impulse toward processing emotions, it is important to be aware of the potential harm from prematurely engaging emotional processing of the traumatic event. In the immediate aftermath of the disaster, it is beneficial to rely on other strategies.

In disaster response, therapists may only meet with clients for one brief intervention or a few sessions, at times without the possibility for follow up. This may occur via a crisis hotline, at or near the location of the disaster, in a shelter or other temporary setting, or at one’s office. The short-term nature of these meetings and varied settings present a challenge for therapists who prefer depth work. When the number of interactions is limited, the therapist’s primary focus ought to be on providing some stability to the crisis response. However, this can be done in a manner that also points clients toward future options. Through offering a compassionate presence, clients can get a brief taste of the healing power of relationship. Additionally, therapists can discuss with clients follow up options, such as considering longer-term therapy.

In considering short-term interventions, various interventions fit better with an existential–humanistic approach. For example, it is common for existential–humanistic therapists to incorporate various breathing, centering, mindfulness-based, or somatic interventions that can be effective in managing emotions. As an alternative to debriefing, defusing is a short-term intervention that typically entails fact finding, identifying thoughts and feelings, and providing support and reassurance (Friedman et al., 2006). Defusing is more focused, but experientially can be adapted to utilize a strong relational context consistent with existential–humanistic therapy, particularly if the therapist focuses on the utilization of presence as part of defusing process. Defusing is not trying to accomplish much, but rather focused on providing some stability in the situation, providing reassurance, and helping clients connect with resources. Furthermore, this can help clients become aware of future therapy options and the value of these.

Providing psychoeducation and normalizing the acute reactions to stress is important in helping clients avoid pathologizing their response (Ruzek, 2006, Serlin et al., 2019; Sword, 2019). The nonpathologizing aspect of this fits well with an existential–humanistic approach. Psychoeducation can help clients understand what to expect. From an existential–humanistic perspective, psychoeducation may discuss the possibilities in what to expect while also emphasizing that each person is unique and may respond differently (see Figley, 2019). The emphasis on the varied individual responses is important to avoid pathologizing clients for “not grieving right” or “not recovering right.” It also may serve to help clients begin recognizing choices and options of which they may not have been aware.

Connecting disaster victims with relational support is critical. Stolorow and Atwood (1992) note,

traumatic affect states must be understood in terms of the relational system in which they take form. . . . Painful or frightening affect becomes traumatic, we contend, when the requisite attuned responsiveness that the child needs from the surround to assist in its tolerance, containment, modulation, and alleviation is absent. (p. 53)

Although Stolorow and Atwood are focusing on children in this quote, this is applicable to adults as well with some adaptations given the additional psychological resources most adults have. Trauma is always best understood in a relational context and how it develops within the person is necessarily influenced by the interpersonal context during and after the traumatic event. The relational context and resources influence whether a potentially traumatic event manifests with long-term traumatic consequences (Shallcross et al., 2016; Sharp et al., 2017). While the therapist may be an important aspect of the relational context, their interaction with the individual is more focused even in the context of ongoing therapy. It is important for the client to connect with other relational support beyond the therapist.

Short-Term Strategies and COVID-19

Many therapists felt unprepared for the necessary transitions to keep clients and therapists safe in the midst of the COVID-19 pandemic. COVID-19 demonstrated that it is important for all therapists to be prepared to adjust their practice in case of pandemics or other disasters that may disrupt usual practice. In consideration of pandemics such as COVID-19, it is important that therapists begin by assessing the current challenges clients are facing in all their complexities. For example, clients may be dealing with multiple issues, including direct impact of the virus (i.e., contracting the virus or having friends or family who have contracted the virus), fears of contracting the virus, school or employment disruptions, financial distress, feelings of isolation, and feelings of existential guilt. There may be implications at the individual and communal levels as well (Olweean, 2019). When interaction time is limited, therapists must be aware of common issues to quickly assess the client’s sources of distress and current needs.

For existential–humanistic therapists, it is important to recognize one’s own human and temporal limitations. In crisis situations, trying to do too much can cause harm to oneself and to the client. Recognizing one’s limitations and focusing on what can be realistically accomplished with the limited time available is vital to effective care. Therapists may need to shift to a more active and directive role in a crisis situation, which moves away from the phenomenological approach generally relied on as primary. While this may not be comfortable for some therapists, it is necessary in addressing the immediate need within the temporal limitations. If it is assessed that the client would benefit from follow-up care, providing a good relational and therapeutic experience can be critical in helping clients feel comfortable seeking out therapy after the immediate crisis situation is mitigated.

Long-Term Strategies

For many disaster situations, the recovery process takes many months or years. The word recovery can even be seen as suspect in this context. If recovery is taken to mean being fully restored to the state of existence prior to the disaster, then this is an inappropriate term. It even can be harmful as it creates unrealistic expectations and neglects the valuable lessons that can be learned from the tragedy. Instead, I am using recovery to mean transitioning to a new state in which most aspects of well-being have been restored, even if looking and feeling different than the predisaster state. Furthermore, recovery can be understood as inclusive of integrating new knowledge and wisdom resulting from honestly facing and working through the crisis situation, which could be viewed as posttraumatic growth.

The aftermath of COVID-19 will leave a tremendous impact on the lives of many people for years to come. Sadly, it is likely that the most vulnerable will experience the most sustained negative impacts. There will be a long period of recovery at the individual, social, and cultural levels. It is important for therapists to be aware of the layers of impact that may influence clients.

Existential–humanistic therapy is well suited for the postcrisis work with clients who have experienced disaster situations or pandemics. There are trauma models, such as whole-person approaches to integrated care, that have strong roots in existential and humanistic psychology (Serlin et al., 2019). Existential therapists tend to be attuned to the tragic elements of human existence and open to exploring these within the therapy context. The influence of Frankl’s (1984) experience in the concentration camps on his therapeutic approach is just one of many examples. In this section, I address a few concepts from existential psychology that are particularly relevant to disaster response.

Existential Guilt

Through labeling a form of guilt as existential, it is claiming that it is ontological (Hoffman, 2018; May, 1958). In other words, this is rooted in human existence as a universal experience. While the experience of existential guilt may be universal, it is experienced uniquely within each individual. Rollo May (1958) argued that existential guilt is rooted in self-awareness and includes a constructive potential. Three different types of existential guilt were identified by May, each connecting to a different mode of being-in-the-world. Existential guilt in the eigenwelt refers to forfeiting or not living up to one’s potential. Umwelt existential guilt connects with the environment or one’s physical world, and may be connected to issues such as one’s role in global climate change.

Existential guilt in the mitwelt mode is rooted in one’s connection with other human beings and the most relevant to disaster situations. Hoffman (2018) states,

This form of existential guilt calls all people toward social responsibility to others, even though the person may not have control over the outcome. This guilt, too, may be connected with complacency or inaction in the face of harm or evil, or the participation in a system in which harms are being perpetuated without recognizing what one ought to recognize or voice concern about what one recognizes but may not be able to change.

This form of existential guilt can be closely connected with survivor guilt. As people reflect on what they did or did not do after the crisis has passed, guilt may become more prominent. This guilt is rooted in human finitude—the limitations that are part of being human.

The helplessness faced by many in the midst of a crisis or pandemic can easily become existential guilt. One may feel they can never do enough. Many who minimized COVID-19 or claimed it to be an overreaction or a hoax may experience guilt as the impact of the virus becomes more evident. Individuals who worry that they may have inadvertently passed the virus to others or believe that they did not do enough to prevent spreading the virus similarly may experience existential guilt. This guilt emerges from believing that one did not do enough to help those who are suffering or through recognition that their privilege protected them while others without that same privilege suffered greater than they did.

Existential guilt easily becomes neurotic if not faced, but when individuals directly face their existential guilt it can become productive (Hoffman, 2018). Existential–humanistic therapists help clients compassionately explore their choices and actions during the time of crisis. When engaging in this process, clients may recognize their moral or other failures. As this existential guilt comes to light, it provides opportunities for clients to decide what they will do with this guilt. Through creatively engaging existential guilt, clients can find healing while being empowered to live more consistently with their values in their life in general and in the face of future times of crisis.

Existential Shattering and Meaning

The concept of existential shattering was developed by Tom Greening; however, Greening never published on the topic (Hoffman & Vallejos, 2018). Instead, the concept was developed by his students and colleagues who recognized the importance of this topic (see Hoxie, 2013; Vallejos, 2015). Hoffman and Vallejos (2018) define existential shattering as, “the sudden and unexpected dismantling, or shattering, of one’s self-conception and worldview as a consequence of an event or process that the individual has experienced.” Similarly, Vallejos (2015) described the experience of existential shattering as a “devastating, unexpected, irreversible event, a trauma, in which one’s fundamental systems of meaning and relating are irreparably shattered” (p. 6).

COVID-19 has been an existential shattering experience for many people. It prompted them to question their basic feeling of security in the world. Watching people fight over toilet paper, water, and other essentials can lead to people questioning their faith in humanity. Increasing awareness of the governmental failures may transition into increased anxiety and questioning. Individuals more directly affected by COVID-19 through the loss of loved ones, loss of employment, or other consequences may be thrown into various forms of existential questioning and struggle.

Clients experiencing an existential shattering need a therapist able to sit with them in their places of despair while helping them find the light of hope in the midst of the darkness. In the midst of an existential shattering, clients often struggle to find hope. If the therapist embodies hope that there is something on the other side of the darkness, this relationally can help sustain the client until they find their own hope. Therapists experienced with working with existential shattering have walked the path through the darkness enough to have confidence that there is something better. Hope, then, can be shared. As LuXun (1921/1959) noted, “ . . . hope cannot be said to exist, nor can it be said not to exist. It is just like the roads across the earth. For actually the earth had no roads to begin with, but when many men pass one way, a road is made” (p. 101).

Existential Anxiety

Van Deurzen and Kenward (2005) note that existential anxiety is different than everyday worrying or neurotic anxiety. Rather, existential anxiety is akin to angst, which they describe as “a natural reaction to the vastness of choice and isolation, a predictable response to the loneliness of individual life and the choice the individual must make” (p. 7). In other words, existential anxiety is rooted in the human condition and a response to the givens of existence. Tillich (1952) states, “The basic [or existential] anxiety, the anxiety of a finite being about the threat of nonbeing, cannot be eliminated. It belongs to existence itself” (p. 19). Threats to one’s existence, or the existence of others, may elicit existential anxiety.

Similar to existential guilt, May (1977) notes that, “Anxiety has meaning. Though part of this meaning can be destructive, another part can be constructive” (p. xiv). Existential anxiety emergent from threats to one’s existence, such as is the case with COVID-19, may prompt reflection that leads to growth. However, when existential anxiety is not dealt with, it easily becomes neurotic anxiety, which is more likely to be destructive. Because it is ontological in nature, existential anxiety cannot be effectively managed through mainstream approaches to control and reduce the discomfort of anxiety. While these strategies may decrease the discomfort, they serve to suppress and avoid the deeper existential questions that are beckoned by the nature of existential anxiety. Rather, existential anxiety must be invited into one’s consciousness and, in therapy, invited into the therapy room. This allows for existential anxiety to be faced directly.

Yalom (2008) noted, “though the physicality of death destroys us, the idea of death saves us” (p. 7). COVID-19 brings opportunities for reflection at the individual, familial, and cultural levels. It encourages people to consider values and priorities, the risks that one is willing to take, and how one’s freedom and way of living impacts others. When the focus is on defending against existential anxiety, one may be drawn toward hoarding toilet paper and other “essentials,” fighting with others over resources, or blaming others for the challenges being faced. However, when existential anxiety is faced directly, it allows one to consider how they want to face the existential challenges surrounding them with integrity.

Existential–humanistic therapists are called to sit with clients in the midst of the existential anxiety and help them confront it. If the therapist focuses solely on comforting the client’s anxiety, they miss the opportunity to delve into the deeper meanings that may be brought into focus when existential threats are present. This is not intended to glorify tragedy or crisis, but rather it is focusing on the opportunities that are present when such crises emerge. In order to do this effectively, therapists must be willing to do their own work. Sitting with such existential anxiety can prompt one’s own angst. Therapists must be willing to look within to find the courage to face their own existential anxiety and be with others as they face theirs. This is not easily accomplished, particularly if the therapist has not done their own work in advance. Therefore, part of the existential–humanistic therapist’s preparation for disaster work must be rooted in doing their own existential work.

Recovering From Isolation

COVID-19 has thrown many into an experience of feeling isolated and fearful of others. As clients reengage their normal routines and relationships, these relationships may feel different. It may not be easy to return to their normal routine and way of engaging others. Although the importance of connecting with social support following a crisis is often emphasized (Olweean, 2019; Young, 2006), the challenges with reengaging are missed. The here-and-now focus of existential–humanistic therapy with a relational emphasis (Hoffman, 2019; Krug, 2009; Schneider & Krug, 2017; Yalom, 1980) allows for clients to work on reengaging through their relationship with the therapist. If therapists are not attuned to ways that crisis, trauma, and isolation can affect relationships, they may miss the deeper work of helping clients reengage in relationships in a meaningful way.

The Necessity of Self-Care

Therapist self-care is a popular topic in the field of psychology (Bush, 2015; Norcross & VandenBos, 2018). In this section, I focus on self-care with Telepsychology as well as some unique existential perspectives on self-care.

Telepsychology and Self-Care

Telepsychology affects therapists physically and emotionally in different ways than face-to-face therapy. For example, staring at a computer for long days can lead to eye strain. It is may be important for therapists to consider glasses that decrease harmful blue light, looking away from the screen for periods of time, and reducing screen time outside of therapy. As noted previously, many therapists experience higher fatigue from Telepsychology. It may be valuable to have additional breaks throughout the day.

Working from home may further isolate therapists from colleagues who provide social support and opportunities for consultation. When working remotely, it may be beneficial to schedule time for video or phone consultation with colleagues. Spending quality time with family members or others who live in the same home may become more important when working long hours of Telepsychology. For therapists who live alone, it is important to find safe ways to spend time with friends, family, and colleagues to avoid feeling isolated and depleted.

As Telepsychology is relatively new, there needs to be more exploration—research as well as more informal exploration—of the impact of this modality on the person of the therapist. As the person of the therapist is a central aspect of existential–humanistic therapy, this is even more vital within this approach. Clarifying the impact of Telepsychology is important to recognize the unique self-care needs not being met through other forms of self-care.

Meaning and Self-Care

Existential–humanistic therapy advocates that meaning is an essential component of helping individuals cope with and transform suffering (Hoffman, 2019; Hoffman et al., 2015). Wong (2012) notes that meaning also is important in promoting well-being. Meaning, therefore, should be a natural source of self-care for existential–humanistic therapists. In times of crisis and change, it is easy for therapists to lose track of important sources of meaning in their own life and work. Meaning can be enhanced through mindful connection of the meaning inherent in helping people and communities who are suffering as well as engaging in meaningful activities during time away for work. Pardess (2019), for example, emphasizes the importance of engagement with pleasurable activities, utilizing the creative arts, and engagement with nature, all of which can be sources of meaning.

COVID-19 hit during a busy period in my own life. When a colleague and friend in China asked if I would do some additional trainings and supervision for therapists in China, I could feel the tension pulling me two directions. I recognized the need for boundaries as part of my own self-care, but also the importance of this work. Despite recognizing the internal tension, I also immediately knew that I would agree to this additional commitment. Although the additional time was tiring, the meaning associated with the work that I was doing was rejuvenating. Yet, I also recognize that the rejuvenating aspect of meaning can only go so far.

Balancing self-care strategies is important. As Pardess (2019) notes,

Traditionally, self-care strategies have emphasized the value of “good professional boundaries” and effective self-care strategies outside the workplace. These alone, however, can lead to emotional detachment by the caregiver. Over-reliance on strategies of avoidance can result in diminished compassion satisfaction. (p. 192)

In my own experience, I have consistently found that when I am detached from my clients, therapy becomes more draining without the benefits of the rejuvenation that is part of a caring, empathetic relationship. Empathy, warmth, concern, and compassion are not just therapy techniques—they are personal and relational qualities that are healing in and of themselves. These can be healing for both the therapist and the client, particularly when combined with a belief in the power of the therapy process. Belief in the healing potential of therapy helps empower therapy through the hope that on the other side of the suffering is something better. Suffering, then, is no longer mere suffering, but suffering for a purpose and suffering with potential.

Yet boundaries remain necessary for balance. Therapists need different types of restoration, including more active and restful forms of self-care. Setting appropriate boundaries can be a way of affirming another source of meaning: the value of oneself. For me, the deepest meaning in life is rooted in compassionately serving others. Yet, I also recognize that when I am overworked my compassion and empathy for others can become depleted, which leads to compassion fatigue (Pardess, 2019). Compassion fatigue negatively affects the restorative qualities of relationships, including relationships with clients. If we do not take care of ourselves, the therapy services we offer will be negatively affected.

Relationship and Self-Care

The importance of relationships in self-care already has been addressed in the context of other forms of self-care; however, it deserves additional attention given its importance. Existential–humanistic psychology is a relationally focused therapy; therefore, it is valuable to draw from the wisdom of this approach for self-care as well. As already discussed, the need for relational support can be heightened when shifting to Telepsychology work. However, in general, relational needs may shift when working with disaster situations. When the need is great, therapists may give more of their time to support others, including clients, colleagues, family, and friends. It is vital that therapists do not neglect their own relational needs.

Time apart from others is an essential part of being with people (O’Donohue, 1998). Therefore, we must balance the interrelated relational needs of time for oneself and time with others. Individuals have different needs in regard to solitude and time with others. This balance may shift when working with disaster response. Therapists must be aware of their changing needs so that they can adapt to the particular situation. It also may be important to give greater consideration to what relationships are engaged with outside of therapy. Personal relationships that are challenging or consume more emotional energy may need additional temporary boundaries. It may be more important to spend time with individuals who are supportive and who understand the strain you are experiencing. For others, it may be important to engage more with relationships that help shift one’s focus to more pleasurable or less stressful activities. While, at times, these may not be as deep of relationships, they serve an important purpose in helping disengage from the stressful work environment and possible rumination about the related challenges.

Conclusion

While COVID-19 is undoubtedly a tragedy, it is a tragedy that can be learned from as a field and society so that we are better prepared for future pandemics, should they occur. While existential–humanistic therapy is often neglected in disaster response, it has much to offer in these contexts. It is important for existential–humanistic therapists to be prepared to adapt their therapeutic approaches to meet the needs of the many who are suffering in times of crisis, which may include being prepared for the use of Telepsychology. As illustrated in this article, this can be done in a manner that stays true to the foundations and values of existential–humanistic therapy.