Tag Archives: Coronavirus

How COVID-19 is affecting our fears, phobias and anxieties

By Lindsey Phillips March 2, 2021

When faced with a new, unknown virus, our anxiety can take over, and we often assume the worst. We indulge our fears. We panic. The uncertainty overwhelms us, exacerbating old anxieties and fears and creating many new ones.

If this reaction sounds familiar, you were likely alive when HIV, the virus that causes AIDS, elicited widespread fear and anxiety in the 1980s. In fact, the HIV/AIDS and new coronavirus/COVID-19 outbreaks share many similarities: an inadequate government response, the stigma attached to having the virus, the disproportional impact on underrepresented groups, and initial confusion over how the viruses are transmitted.

At the onset of the AIDS crisis, people incorrectly assumed that they could get HIV by kissing another person. Michael Soderstrom, a licensed professional counselor at Houston OCD Counseling in Texas, remembers his own anxiety when first hearing about HIV and AIDS. He says he didn’t want to sit on a public toilet for fear of contracting HIV.

There’s no doubt that the COVID-19 pandemic has changed us. The question is, in what ways will it continue to change us? Will we ever shake hands again? Will we wear masks each year during flu season? Will we learn from the lessons of previous health crises? One thing is clear already: The pandemic is reshaping not only people’s fears and anxieties but also how counselors are having to approach treatment.

Fear of contamination and harming others

What about people who wrestled with contamination fears before this pandemic? Have they experienced an increase in symptoms? Soderstrom, an American Counseling Association member who treats obsessive-compulsive disorder (OCD) and other anxiety disorders, has observed that his clients who fear contamination from blood, semen or bodily waste have not gotten worse, because quarantine largely takes them away from exposure to these “contaminants.” But he has noticed an increase in clients who worry about contracting diseases, getting sick or dying, as well as those with perfectionist tendencies who struggle with the fact that COVID-19 ultimately lies outside their control. The thought that they could contract the disease regardless of how carefully they follow safety precautions terrifies them, he says.

The pandemic has even given rise to a new phobiacoronaphobia, the fear of contracting COVID-19.

People with OCD are also at risk of backsliding right now because the isolation, heightened stress and uncertainty associated with the pandemic can lead to depression and generalized anxiety, which fuel OCD-related symptoms, says Soderstrom, a member of the International OCD Foundation and OCD Texas. He has seen several new clients who had previously dealt with OCD symptoms on their own, but their symptoms became unmanageable during the pandemic, causing them to seek professional help.

To some degree, everyone is concerned about cleaning and sanitizing right now, so when do these thoughts and behaviors cross over into becoming a problem? Soderstrom asks clients who struggle with contamination fears to establish a safety practice based on guidelines from a trusted health organization such as the Centers for Disease Control and Prevention (CDC). He also has clients record how often they are cleaning surfaces to help them recognize if their behavior is becoming problematic.

If clients realize they are going beyond the CDC guidelines and washing their hands obsessively, Soderstrom has them establish rules on when they should wash their hands, such as after using the bathroom or sneezing. He also encourages them to limit themselves to washing with soap and water for 20 seconds. At first, these clients may feel the need to also wash their hands every time they touch the front door because it could be contaminated. Over time, Soderstrom may ask them to simply “water wash” their hands after touching the front door. This fulfills their emotional need without the full brunt of soap and water. These ground rules serve to keep people anchored in reality because someone who wants certainty can always find a reason to wash or clean, he adds.

Soderstrom has also noticed an increase in clients who worry about infecting others with the coronavirus. These clients struggle with what is known as “harm OCD”; they are the same people who worry about hurting or killing someone with their actions, he explains. To illustrate, these clients might grab a doorknob and think to themselves, “I hope I have the COVID-19 virus and will give it to my mom.” But then they quickly reject this thought and obsessively clean the doorknob out of fear that they will actually give their mother the virus.

Over-responsibility is a substantial issue with OCD, Soderstrom continues. Some clients feel responsible for not protecting others from the coronavirus, so they are constantly cleaning commonly touched surface areas such as car-door handles before others use them.

With these clients, Soderstrom often uses a responsibility pie exercise. If a client is worried about giving their older parent the COVID-19 virus and killing them, then he would ask, “What are all the other ways they could get COVID-19? How many times have they been to the store? How many times have other people come over to their house?” This exercise helps clients realize that assuming full responsibility for the possibility that someone else could get COVID-19 is not realistic, he explains.

Soderstrom also finds this exercise personally helpful. Whenever he has intrusive thoughts about the possibility of getting COVID-19, he asks himself, “What ways could I get the virus? If I did get the virus, who would be responsible — me, the government or the people I’m around?” Thinking through these questions helps him realize that even if he did get COVID-19, it would not automatically mean that he had been irresponsible or was a failure. Because myriad factors are at play, he knows he can only do the best he can to stay safe; the rest, ultimately, is outside of his control.

Relationship and separation anxiety

In the coming months, Rocio Morris, a licensed mental health counselor and the assistant clinical director at the Bougainvilla House in Fort Lauderdale, Florida, believes counselors will see an increase in relationship issues. She has already noticed that more of her clients are coming to therapy because of attachment and communication issues within the family. For example, one of Morris’ clients is in a codependent relationship with her mother, and the mother’s anxiety over the pandemic is in turn affecting her. The mother constantly worries about the family contracting the virus, which only serves to increase the daughter’s anxiety.   

In addition, a few of Morris’ clients are having identity crises because they are isolated and trying to figure out who they are in the absence of their normal support networks. One client in particular is actively grappling with her sexual orientation, but she is doing this alone in a home with a mother who is unsupportive and two young siblings. Before the pandemic, this client would have found support through school activities or by hanging out with friends who were having similar experiences. Now, she feels trapped and all alone in her house.

To complicate matters, the client has a history of self-harm. Morris, an ACA member who specializes in working with teens and adults struggling with anxiety, depression, behavioral issues and life transitions, is working to cultivate the client’s inner strengths to help her through this challenging time. For example, because the client is artistic, Morris has encouraged her to use expressive coping techniques. So, when the client feels the urge to harm herself, she opts to paint that part of her body instead.

Morris, owner of the private practice Reimagine Life Counseling Services, thinks these types of relationship issues are likely to increase. Once pandemic-related restrictions are lifted, some people will be anxious to leave home or to be apart from certain family members, whereas others will start dealing with the outcome of being stuck in a toxic environment for months on end, she says.

Soderstrom believes counselors may see an increase in clients who are panicked about leaving home and being away from family members because they have grown more attached during the pandemic. “It’s like a part of who we are didn’t get exercised [during the pandemic] and got out of shape,” he says. “We have to exercise that part of ourselves again to be our full selves. … We have to reexperience fear. We have to reexperience doubt. We have to reexperience … emotional isolation outside the house.”

Soderstrom knows how much isolation can affect someone’s social anxiety. A few years ago, he had an extroverted client who lived overseas with his father for an extended period of time. The client mostly stayed isolated inside his apartment because he didn’t speak the local language. When he returned to the United States, he came to see Soderstrom because he had developed social anxiety about reconnecting with his friends. The extended break from his social activities had affected his self-confidence, and he found it easier to avoid his friends, which only reinforced his anxiety, Soderstrom says.

With Soderstrom’s help, this client overcame his anxiety, but Soderstrom worries that once the need for physical distancing finally passes, more people will struggle with social anxiety and panic disorders because they too have been isolated for extended periods of time. He predicts that some people will find social situations such as going to the mall or being around large groups of people triggering at first.

“Because this [pandemic] is such an individual experience for everybody, people are going to come out of this or move forward from this with different [experiences], such as losing somebody or experiencing trauma in the home,” Morris observes. These differences will affect how people learn to interact with one another again, she adds. 

Confronting, not avoiding, anxiety

Clients often come to see Andrea Batton, a licensed clinical professional counselor and the clinical director at Maryland Anxiety Center, and ask her to “get rid of their anxiety.” No one wants to feel anxious or afraid all the time, of course, but the treatment goal isn’t to completely eradicate these feelings, she says. Batton, an ACA member who specializes in treating anxiety and OCD-related disorders, explains to clients the adaptive nature of these emotions, which includes informing us about our environment and helping us to survive. The point of counseling is to learn how to respond to these emotions in more helpful ways, she says.

Similarly, Soderstrom advises his clients not to ignore these thoughts and feelings but rather to be curious about them. Too often, he says, clients try to run away from these thoughts. “We try to control thoughts by either getting rid of the trigger or avoiding the trigger,” he explains. His goal is to get clients to embrace their emotions by capturing the thought and refocusing their energy back into their body or on another thought they value more.

So, if an adult child is eating lunch with their father and they have an irrational fear that they have the COVID-19 virus and just gave it to their father by hugging him, they can pause and acknowledge this intrusive thought as one that may feel true but isn’t. They can ground themselves by shrugging their shoulders, remind themselves of the low likelihood they are giving their father the virus, and refocus their attention on what they will discuss during lunch.

“The art of refocusing gives us ultimate power,” Soderstrom says. “It’s the moving on or refocusing on something we value or something that’s important that teaches us to devalue whatever the [intrusive] thought was rather than avoiding it.”

Although this isn’t the intent, physical distancing guidelines are encouraging many people to avoid the stimuli that trigger their anxieties or fears, and this can have serious repercussions on their overall progress, says Batton, a member of the International OCD Foundation and a board member for OCD Mid-Atlantic. Some school-age children, for example, struggled to go to school before the pandemic because they wanted to avoid situations that might trigger worries about having a panic attack or a specific phobia such as a fear of vomiting. Virtual classes — which have become common during the pandemic — serve to reinforce avoidant behavior.

“Avoidance is a compulsive behavior that reinforces the notion that there is danger at school,” Batton says. So, she wants to see these students return to in-person instruction full time. The same goes for clients who want to avoid work or other settings that trigger anxiety, phobias, or OCD-related worries or fears.

Counselors will have to work with their clients to figure out plans to ease them back into these spaces once it has been deemed safe to do so, Batton continues. “We don’t want anxieties, worries and fears to limit your life,” she says. “We want you living in accordance with your values [and] life goals, not [with] what anxiety tells you to do or your fears tell you not to do.”

Reappraising negative thoughts

When people are triggered, their mind automatically goes to worst-case scenarios, says Batton, a member of the Anxiety and Depression Association of America. When clients struggle with worst-case-scenario or all-or-nothing thinking, also known as “thinking traps,” counselors can help by teaching them how to respond to their thoughts more rationally, she continues.

Cognitive reappraisal isn’t about “looking on the bright side” or trying to be positive, Batton notes. Instead, counselors should help clients consider other possible explanations and look at what else might be going on. For example, if a student is struggling in a virtual class, they may start to think, “I’m going to fail the class. Everyone else understands the material. I’m stupid.” These thoughts will only make the student feel more anxious about the class, so they will dread doing homework or even avoid going to the class again, thereby reinforcing these less rational thoughts, she explains.

Batton’s goal instead is to teach the student to take a step back and consider what else could be true about the situation. Maybe the other students are also confused. Maybe the class is difficult. Maybe the student won’t get an A in the class, but they will still pass. After challenging the negative belief, the student can engage in more adaptive and helpful behaviors such as starting a study group or speaking with the teacher about how to improve in the class.

This cognitive reappraisal technique helps clients change the way they respond to intrusive thoughts over time. “When you’re having more rational thoughts, you’re going to feel more neutral. You’re not going to feel as anxious. You’re not going to feel discouraged … or afraid,” Batton explains. These neutral emotions and rational thoughts lead to more productive behaviors, which in turn fuel more rational thoughts. 

Morris says many of her clients are falling into thinking traps when it comes to the pandemic. She often relies on thought-stopping exercises to help them get unstuck and move forward. If a client is afraid to leave their house because they may get the COVID-19 virus, she helps them identify the trigger and stop the negative thought before it snowballs into a physical reaction. She asks the client, “What is one small thing you can do to feel more in control?” Maybe they could put on a mask and go for a careful walk around their neighborhood rather than locking themselves inside their house.

Morris also shows clients a few common thinking errors such as negative labeling (e.g., “I’m stupid.”), blowing things up (e.g., “This pandemic will never end. I’m going to live alone forever.”) and self-blaming (e.g., “My neighbor has COVID-19. I probably gave it to them.”). She then asks them to identify which ones they are experiencing. This helps initiate the conversation and individualize the coping skills the client needs to respond to these thoughts, she adds.

Soderstrom helps his clients engage in logical, rather than emotional, thinking by asking Socratic questions. For a client who worries that they didn’t clean the doorknob well enough and may be responsible for giving their family the COVID-19 virus, Soderstrom would simply ask, “Would you bet $10,000 that if a scientist came and swabbed the doorknob, they would find the virus? What’s the evidence for this thought? What would you tell your friend if they were in a similar situation?”

He also asks clients to complete a thought record that consists of seven columns: the situation/trigger, feelings, unhelpful thoughts/images, facts that support this thought, facts that challenge this thought, an alternative (more balanced) perspective and the outcome. This activity anchors clients and pulls them away from black-and-white thinking, he says.

Rethinking exposure therapy

As Batton points out, exposure therapy is the backbone of clinical treatment for anxiety and obsessive-compulsive and related disorders. But not all exposures are possible during a pandemic. Asking a client with social anxiety to go to a large party is bad therapy right now, Batton jokes.

For that reason, counselors have to get creative with their exposure ideas. For example, Batton is using a HIPAA-compliant version of Zoom and Bluetooth to “ride along” with her clients who have driving phobias. This allows her to still see clients’ facial expressions, such as a clenched jaw, while she coaches them during the exposure. When she has a client with compulsive bathroom rituals, she sets a timer and virtually watches them brush their teeth to limit how long they engage in this behavior. Batton also helps clients with emetophobia (a fear of vomiting) by making fake vomiting noises together during the virtual session, sharing her screen to look at photos of vomit and watching video clips of other people vomiting.

Regardless of how the exposure occurs, the goal is to initiate those intrusive thoughts and anxieties to help clients realize that their worst fear is unlikely to occur. Through this experience, they don’t “unlearn” the fear. Instead, they gain “new safety learning” or inhibitory learning (i.e., learning that the feared stimuli and their emotional response to it are safe) and habituate to the thoughts and uncomfortable feelings, Batton explains. The fearful thoughts lose their power and diminish over time, she adds.

Before the pandemic, Soderstrom rarely went into clients’ homes to do exposure therapy. Now, with the transition to telebehavioral health spurred by the pandemic, he regularly enters clients’ homes virtually and works on their phobias and anxieties in real time. For example, one client fears losing control and accidentally stabbing her grandmother. Previously, as part of treatment, he would ask the client to take a plastic knife and sit beside her grandmother or hug her as a homework assignment. Now, he can observe her while she actually performs this exposure exercise.

Soderstrom is also finding inventive ways to help clients focus on their core fears. For example, he’s asked clients with social anxiety to call someone on the phone and post new videos on TikTok.

Virtual exposures have actually expanded Soderstrom’s options for treatments because, as he points out, “so many obsessions/compulsions are done inside the house.” So, he plans to continue virtual exposure sessions even after he returns to having in-person sessions. He likes that the virtual exposure sessions provide him with visual, not just written, evidence of clients’ progress.

Batton finds that virtual exposures have provided cost-effective treatment options for her clients. Before the pandemic, she had to charge a travel fee every time that she conducted an in-home visit to do exposure work. Because of the pandemic, and thanks to telebehavioral health, in-home visits have been eliminated, and because exposure therapy is typically as effective virtually as it is in person, she plans to continue this practice on occasion after the pandemic-related restrictions end.

Counselors’ own fears (and hopes)

At the beginning of the pandemic, Soderstrom worried he would lose his connection with his clients. He thought he wouldn’t be as effective as a therapist because of the physical distancing restrictions. But Soderstrom was happy to learn his fears were unsubstantiated. He just had to adjust his technique and become more vulnerable with his clients.

With telebehavioral health, clients may not be able to pick up on the counselor’s body language, or they may not feel comfortable being vulnerable themselves, Soderstrom says. He finds that being open and honest about the way he is feeling often elicits clients to be more open with him. For example, he recently told a client, “Sometimes, I feel like it’s hard to do treatment right now.” This prompted the client to share that they also found therapy difficult. The client hadn’t been able to finish their therapeutic homework assignments that week and had even considered quitting therapy. Soderstrom reassured the client that they weren’t alone in this feeling. 

Morris believes that counselors need to keep suicidality on their radars in the coming months and years. The suicide rate among teenagers has already been rising, and one must assume that the job losses, isolation and loss of life resulting from the coronavirus pandemic will only push that rate even higher, along with suicidal ideation among both teenagers and adults, she says.

Morris emphasizes the importance of counselors doing more outreach during these times. She recently hosted a webinar for a local high school on how COVID-19 is affecting teenagers and discussed the warning signs of suicide as a preventive measure. By providing psychoeducation, she hopes to normalize conversations about suicidal ideation and prevent future suicides.

Batton’s biggest fear for the profession itself is that many counselors will choose to engage with clients exclusively through telebehavioral health even after the pandemic danger has passed. She acknowledges that returning to in-person sessions may not be easy or straightforward for many clinicians, especially if they had to break the lease on their office spaces. But she hopes most counselors will find a way to return to an office in some capacity. Batton longs to see clients and counselors interacting in person again, in part because in-person sessions are beneficial for clients who struggle with certain fears and anxieties such as social phobias, she says. 

Morris shares Batton’s concerns about the possibility of counselors not returning to their offices. She’s currently hiring counselors for her clinical office and has found many of them are still fearful of providing in-person sessions, even after taking the appropriate precautions of wearing masks and sanitizing between sessions. Morris acknowledges that the whole process has been unsettling for many clinicians. First, they had to quickly adapt to moving their practices online; now they are being told they can go back into the office with safety precautions. She wonders, “How long is it going to be before counselors feel comfortable again with face-to-face sessions?”

Soderstrom says some of his clients are worried about the potential consequences of the prolonged suffering experienced over the past year because of the pandemic. Others with anxiety disorders and OCD fear that if their situation gets too tough, they might implode or incapacitate themselves with worry. He reassures them that humans are strong and can adjust to even the worst circumstances — just as they have done before.

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Working our way through a pandemic

By Laurie Meyers February 25, 2021

To appropriate a turn of phrase from Queen Elizabeth II, 2020 was our collective annus horribilis (horrible year). The queen was referring to 1992, a year that featured the implosion of three royal marriages, a devastatingly destructive fire at Windsor Castle, and unfortunate headlines involving Sarah Ferguson’s new beau and his, ahem, admiration of the Duchess of York’s feet.

But as the meme goes, 2020 said to 1992, “Hold my beer.”

The year that the queen “shall not look back upon with undiluted pleasure” included family losses, property destruction and embarrassing press. Stressful, to be sure, but ultimately personal and mundane (although, granted, most of us don’t have to face the paparazzi). But 2020 pelted us with events of a virtually seismic nature that have in one way or another affected billions of lives worldwide. The emergence of the novel coronavirus was not the only stressor or calamity the year visited upon us, but it remains arguably the most disruptive. And perhaps nowhere is that more apparent than in people’s work lives.

When the great shutdown began in the U.S. in March 2020, most of us thought we’d be confined to the house and working virtually for only a few months. But approximately one year later, and with more than 450,000 American deaths attributed to COVID-19 through the first week of February, many people are still hunched over their makeshift office equipment.

In the beginning, some of the work-from-home snafus were funny. Newscasters broadcasting with jackets — but no pants (which seems to be the preferred work-from-home style for a surprising number of people). The boss who accidentally turned herself into a potato on Microsoft Teams and didn’t know how to change back. Amusing, embarrassing and sometimes horrifying comments and conversations caught by accidentally unmuted microphones in video conferences. Other disruptions, such as cats on the keyboard and dogs chiming in during meetings, were a bit chaotic but too cute — at least at first — for their human companions to truly complain about. But other people struggled to carve out a workspace and found themselves joining meetings from underneath the stairs or barricaded behind the bathroom door because it was the only private space in a house full of busy (and noisy) family members. Even people who frequently telecommuted pre-pandemic often found adapting to an all-virtual workplace a challenge.

Balancing work, school and child care

One of the most significant challenges to working — whether virtually or on-site — during the COVID-19 era has been the lack of child care options and the need to assist children with their virtual schooling.

“Coaching folks on how to handle their work life without child care is a big focus of my practice these days,” says Katie Playfair, a licensed professional counselor (LPC) and management consultant located in Portland, Oregon.

“I tell clients to be as flexible and creative as they can in figuring out how to get their job done despite these obligations and to consider, when possible, cutting back hours to something more manageable,” she says. “As the mother of children who are 8, 6 and 2 years old, I home-school them during the day and then work from 5 p.m.-10 p.m. every evening after my spouse gets home. It’s a rough schedule.”

Playfair says many parents are having to take breaks to help with schoolwork during the day and then catching up on work themselves at night. Even children who are old enough not to need constant supervision often interrupt the workday to request a snack, to seek permission to take a break or to ask a quick homework question. As a result, parents are continually task-switching, unable to block out time for uninterrupted work, Playfair explains.

“Developing a system to communicate with older kids about when parents are interruptible and when they aren’t is vital,” she stresses. The use of physical or virtual calendars, door signs or predetermined “office hours” when they will be available to their children can help parents protect meeting times and allow for concentrated work during the day, she says.

“Providing kids with a way to table their questions until appropriate times is the other side of this equation,” Playfair continues. “They may need a whiteboard on parents’ doors or some other ways of tracking things so they don’t forget about them and get frustrated. Older kids can also be taught to email or text parents. Nonetheless, parents may still find themselves having to work nights or weekends to make up for the work that isn’t getting done during the school day.”

Even with families in which one spouse was already a stay-at-home parent before the pandemic, the virtual work and school mix can throw a wrench into the routine, says Keri Riggs, a Texas-based LPC whose specialties include relationship stressors, stress management and work-related issues. In one couple with whom Riggs worked, the mother was accustomed to structuring her day around the schedule of their middle school-age children. The family had managed to incorporate virtual school into their routine when, suddenly, the father began working remotely.

The only available workspace was the kitchen table, and the husband frequently needed everyone else to clear out of the room so he could participate in meetings. But he also recognized the need to give his wife a break — and the need to get away from the table himself — so they scheduled in lunches and other times when they would trade responsibility for the children. Because his meeting schedule varied, the couple sat down every night and plotted out the next day’s schedule, blocking off times when the kitchen needed to be in “do not disturb” mode and carving out time for breaks, says Riggs, a member of the American Counseling Association.

Fitting in the demands of work and school is even more difficult for single parents because, absent an available and willing relative or neighbor, there is no one to help shoulder their burden. Uninterrupted blocks of time may be available only when the children are asleep. However, some work-related tasks, such as meetings and phone calls, generally have to take place during the day. To help minimize disruptions, Jessi Eden Brown, an LPC whose specialties include trauma and workplace bullying, suggests parents buy or create “some kind of super-involved art project that they [children] only get to work on during meetings, so it’s kind of like a treat.”

“I don’t love this,” she continues, “but some clients have [also] had success with a television show or movie that can be started or stopped.” Brown, an ACA member, recognizes that isn’t an ideal solution, but it may be the only way that some clients can prevent interruptions in meetings. As she tells parents, with all the stressors they’re coping with, an extra hour or two of television here and there for their children is not the end of the world.

Of course, as Sharon Givens, an LPC who specializes in career development and mental health, points out, “Not everyone was able to just pick up a laptop and go home. If you’re a housekeeper, you can’t work from home.”

This is particularly problematic for single parents, she says. Some of her clients have family members who can assist with child care during the day, but others have had to relinquish their jobs. They are experiencing devastating financial difficulties that were exacerbated by the end of federally supplemented unemployment benefits.

“And, so, we’re working together to create some strategies to pay the rent,” says Givens, president-elect of the National Career Development Association, a division of ACA. Some clients have pulled money from their retirement accounts or tapped family members for financial assistance. Givens has also helped clients find local assistance programs and search for jobs that they can do from home.

The pandemic and resulting recession have demanded that counselors put on their “practical strategy hat” to help clients, Givens says. She has advised clients to speak with their mortgage company or landlord and their utility companies to see what type of deferment or other relief they can offer.

Setting boundaries and navigating distractions

The virtual office poses other challenges, such as the blurring of boundaries between work and home. By getting rid of the daily commute, office workers have gained extra time, but it has also deprived them of a natural boundary that signaled the beginning and end of the workday, Riggs says. The computer is always right there — a siren beckoning workers to check their email one last time or to do just a little more work. Suddenly, it’s midnight, and they’ve spent all day at the computer.

Riggs works with clients to replace the commute with other routines, asking what symbolizes starting and ending the workday for them. Is it taking a shower or changing out of their work clothes at the end of the day? She also suggests engaging in rituals such as hanging a “closed” sign on the computer or home office door or voicing a mantra such as “I did my best today.”

Sometimes, however, it isn’t employees who have trouble setting boundaries. American work culture is often brutal and not supportive of health and well-being, Playfair asserts.

“Unless an organization has set out to really change themselves into a more compassionate and empathetic place to work, they’re going to expect lots of hours, productivity and performance from everyone nearly all the time,” she says. “But even within this culture, there are opportunities for boundaries. First, I encourage people to ask their bosses, ‘Do you want the truth or what I think you want to hear?’ when an employee feels pressured past what they can take. Most people will choose the truth, and that will give the opportunity for healthy disclosure. I also like the phrase, ‘I wish I could do that for you, but I can’t because …’ to introduce a boundary.

“Finally, I think it’s helpful for employees to empathize with their bosses while still demanding support themselves. For example: ‘I understand that you’re short-staffed for this shift and that headquarters is expecting you to figure it out. That’s unfair. If our company would budget and plan sufficiently for contingency staffing, this wouldn’t be a problem for you or me, would it? I know they expect you to be fully staffed today, but they haven’t given you the resources to be successful with that, and I can’t personally make up for their poor planning.”

Brown encourages her clients to look for fellow employees who seem to be able to set boundaries. “Like ‘Bob’ — he always seems to sign off at 5. How does he do it?” she asks.

In other cases, Brown and the client may review their job description or the company’s policies and procedures manual to see if expectations for work hours have been set out.

Home itself can often be a distraction, Riggs notes. It can be difficult for people to focus exclusively on the work they are paid to do when they are surrounded by ever-present reminders of household tasks that also need to be completed, such as doing the laundry or loading the dishwasher. Cell phone pings announcing texts and social media notifications also beckon.

Riggs and her clients try out different solutions to find what works. This might involve setting a timer to complete 30-minute blocks of focused work, giving themselves a healthy reward for completing work, or setting up accountability partners. Riggs also suggests that, if possible, clients leave their cell phones in another room. If that isn’t feasible, she encourages clients to disable their notifications. She also counsels clients to prepare for the unexpected by allowing some margin for “white space” — a block of free, unscheduled time — during the day to attend to urgent requests or time-sensitive tasks.

The mental toll

Working under less than optimal conditions — or not working at all — has created significant challenges among a population that is already struggling with grief, Givens says. “All of us, if we’re being honest, are feeling a sense of loss: loss of activities, loss of career opportunities, loss of income.”

The uncertainty ushered in by the pandemic has challenged many clients’ coping skills, Givens says. She uses a variety of methods to help, including exploring what methods have supported clients’ ability to cope in the past. For some people, that involves more physical activity, whereas for others, it’s about increased (virtual) connection.

Givens also uses cognitive behavior therapy interventions such as having clients keep a thought record. They then look at this together and evaluate what is and what isn’t under the client’s control. “Many of them see the visual: ‘I spent four hours per day worrying about something that I couldn’t control,” she says.

Many of her clients are also engaging in frequent catastrophizing, obsessing about what will happen and whether they’re going to die in the pandemic. These concerns are natural, but some clients are mentally building worst-case scenarios, Givens notes. For these clients, she uses a different kind of thought record known as an evidence record. The concept is the same — clients write down their thoughts and then go over them with Givens — but what they’re looking for is any evidence to support the likelihood of their worst-case scenarios becoming reality.

All of the practitioners Counseling Today spoke to for this article urge clients to be patient with themselves as they navigate the myriad challenges of working during the COVID-19 era. Riggs recommends Kristin Neff’s five-minute self-compassion break (a guided version is available at self-compassion.org/guided-self-compassion-meditations-mp3-2/).

The practice begins by, as Neff puts it, “calling up a little suffering,” or reflecting on something that is currently causing stress or worry. Neff then provides a series of phrases “designed to help us remember the three components of self-compassion when we need it most.”

The first phrase is “This is a moment of suffering.” Or, as Riggs tells her clients, “I’m having a hard time today. I’m struggling.”

The second phrase is “Suffering is a part of life.” Riggs describes this as recognizing one’s connection to all of humanity: Not only am I struggling, other people struggle too. I am not alone.

The third phrase is “May I be kind to myself in this moment.” To support being kind to oneself, Neff suggests that listeners place their hand over their heart or another place on their body that feels soothing, then focus on the warmth of their hand and let that sensation stream through their fingers. She then recommends that listeners direct kind and supportive language toward themselves, such as words they might use with a friend going through a similar situation — e.g., “I’m here for you. It’s going to be OK.”

At the end of the practice or “break,” Neff asks listeners to notice how their bodies feel and to allow themselves to just “be” in the moment with those sensations.      

Riggs also suggests clients ask themselves what would make them feel better at that moment. “That’s really the hardest piece if you don’t know what you need,” she says. “Do I need to move my body? Do I need to journal? Call my best friend? Put on music? Give myself a hug?”

Finally, Riggs tells clients to remind themselves that the stress or anxiety they are currently experiencing will not last forever — that they won’t feel like this forever. Eventually, it will change.

Amid the suffering caused by the pandemic, Brown sees opportunities for personal growth. “Never before have we had … [such a] profound opportunity to slow down and focus on life’s priorities with such intention,” she says. “COVID-19 has affected nearly every person on the planet. Countless people live in fear, and many have lost family, friends, livelihoods and so much more.

“The tragedy is undeniable. That said, I have always believed that low moments like these potentially set the stage for meaningful change as we reflect on what is important and how our decisions either support or impede our progress.”

 

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The pandemic and a frayed political climate have also been at the center of various instances of workplace bullying. Read more in our online exclusive article, “No rest for the bullied.”

 

 

 

 

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Laurie Meyers is a senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Online role-playing games as group therapy during the COVID-19 pandemic

By Per Eisenman and Ally Bernstein February 18, 2021

During the challenging era of COVID-19, many young people are experiencing the sort of isolation that can interfere with healthy social development. This may be particularly true for young people who were already wrestling with significant mental health challenges before the pandemic. Telehealth group therapy that utilizes role-playing games offers a hopeful modality for facilitating individual growth in a group context.

Setting the stage

When one of us logs in to the Zoom session 10 minutes early, a picture of a cat immediately pops up. Martin has been waiting all morning for the group to start. He appears briefly and shows us his cat, Betty, sitting on his lap, before turning the video off so that only the photo of Betty is visible.

Gradually, everyone else joins and our game begins. Martin is committed to the group; he has never missed a session and is always early. In Dungeons and Dragons and other role-playing games, group members play fantastic adventurers, working together to overcome obstacles and gain rewards. The facilitator narrates a story, and the group members describe how their characters respond.

Martin plays an elf wizard named Sylvan who has a cat (also named Betty) as his magical animal companion. Martin was initially a bit shy but has integrated into the group and participates in collaborative decisions; he also loves to talk about Sylvan’s cat and backstory. Martin joined the group after the COVID-19 stay-at-home order in the spring of 2020, once we moved to a virtual environment. As is the case with some others in the group, this is Martin’s only social contact outside his family.

The therapeutic group allows for a structured social interaction — a place where people can connect, practice social skills, and modulate their inner and outer worlds. Many of the young people we work with experience social anxiety, depression or social skill deficits. The experience of a safe social setting where they can experiment with becoming someone else allows them to develop connections that can be both an antidote to loneliness and an opportunity for growth.

The COVID-19 pandemic has been a time of isolation. Young people especially are having fewer opportunities to develop socially, and schools are not able to provide as many opportunities for social contact. Telehealth group therapy using role-playing games creates opportunities for social connection and resiliency-building that may not be possible in person during the pandemic.

Collaborative creativity

Role-playing games hold a place in the pop-culture imagination as a niche interest, but their popularity has increased in recent years, and therapists have started implementing the games more widely as a group therapy modality for older children and adolescents. In role-playing games, one facilitator describes an imaginary world, and the participants (playing characters) describe their actions in that world. Sometimes success and failure are based on dice rolls, but players’ creativity and collaboration are also key in helping a group achieve its goals within the world. The game has many decision points, and each player can change the course of the story.

Martin’s character, Sylvan, has blasted open treasure chests with fireballs, duped goblins by pretending to be their grandmother, and hatched a dragon egg. Martin’s creativity influenced the world for himself and the other players, creating a new set of circumstances and changing the direction of the story.

During the game, the facilitator sets the stage: “You enter the pirate’s cavern. As you go in, you see a couple of pirates standing guard.”

The group members discuss how they would like to respond. Should they fight the pirates or try to sneak past them?

“Let’s trick them,” Maya suggests enthusiastically. Maya is shy in real life, but in the game, she plays a tough brute who likes smashing down doors. Martin’s character is cunning and enjoys deception. He likes the idea, and they work together to come up with a ruse.

Martin’s character says, “We are poor pirates who have lost our way in the tunnels. Could you tell us the way to the ship?” He rolls the dice to see whether he can convince the pirate guards to let them pass.

Traditionally, role-playing games are played in person, sitting around a table with maps of the adventure setting, rolling dice, and telling the story together. However, it is possible to play the games remotely through videoconferencing and the use of online platforms. In recent years, remote role-playing game use has increased dramatically. The virtual medium confers new benefits during the COVID-19 pandemic and in an era of physical distancing. It translates surprisingly well to a telehealth group therapy experience. Martin, who struggles with social anxiety, told facilitators, “I like playing online better. I can turn off my video.”

Emergence of change

In the many groups we have run with colleagues, we have observed the emergence of group dynamics and group member interactions that have influenced the choices members make and their participation in the group. Some group dynamics become apparent through the group members’ interactions with one another or from the progress of the group over the course of many sessions. Other patterns emerge in the development of individual group members and the impact they have on the group.

We were particularly struck by the memory of Kendra, who had a very clear vision of how she wanted the game to proceed. She wanted to control the narrative so badly that she soon began frustrating the other players.

“Can I roll the dice to persuade Maya that she should give me her gold?” Kendra asked. She prioritized stealing gold or impressing pirates controlled by the game master over helping the other characters.

This led to frustration among the other group members. Some members began to go silent. One spoke out angrily against Kendra, suggesting the group members’ characters fight Kendra’s character. The frustration of the group turned into a discussion, and Kendra ended up changing her character’s behavior entirely, deciding that her character needed to work with the group and eventually save them, sacrificing herself for the greater good.

She said, “I want my character to help the group, but the shift has to make sense for her character arc. She can’t just change overnight.” We had numerous discussions about what it might mean for her character to develop.

We asked the other group members what they valued about the game, and another member said, “Working together as a team.” The emotional message felt palpable. We were thrilled that the adolescent participants were able to lead this discussion themselves and process as a group with only minimal prompting from the adult facilitators.

Role-playing games involve the players describing the actions of their characters, while the game master describes the rest of the world and the people who inhabit it. The world is imaginary, and visual aids are optional. In a therapeutic group, this system allows for group members to explore identity construction and navigate group dynamics. Therapy groups for teens support the essential task of identity development in the context of relationships with peers and adults.

Much like with any good therapeutic group, what happens within the context of the game often reflects the members’ lives out-of-game. When the game master is also a therapist, questions such as “How are you similar or different from your character?” and “Why did your character make that decision?” make the game a clinical experience. The avatar of the character allows each group member a safe distance through which to explore, process, experiment, fail and succeed.

Group process as an adventure

Role-playing games have long been an effective group therapeutic modality, but creating a shared imaginary world presents unique opportunities during the COVID-19 pandemic, when we are unable to safely convene in person.

Every age has different developmental tasks to achieve, and during the pandemic, these tasks have either been interrupted or have required us to make notable changes in how we carry them out. With schools shifting the way education is delivered because of the pandemic, the amount of social interaction has been significantly reduced. On the whole, we are spending more time isolated from others, and young people are having fewer opportunities to develop socially. Role-playing games, a high-interest activity, allow for social experiences to happen through telehealth in a way that might currently be impossible in person.

Role-playing games feature goals, conflict, choices and relationships. Young people can do something together by completing tasks that require creativity and teamwork. Playing every week creates routine and ritual. Having a group means that young people have regular contact with adults and peers outside their immediate family.

Games can be adapted for different age groups and needs. Children and adolescents can develop executive function and practice resiliency. The technology necessary to play the game online can malfunction and lead to frustration, allowing participants to practice patience and engage in troubleshooting. Also, because the games are fun and silly and joyful, the fantasy setting can provide everyone with a much-needed break from the stress and grief of the current world (or a way to process grief and loss, because characters can die too).

This innovative form of group telecounseling provides an opportunity to engage young people who might not otherwise actively participate in a group process. It also provides an opportunity to support the cultivation of interpersonal relationships with group members in serious need of social skill development. Right now, during the pandemic, if we want to offer something that simulates living and striving in close proximity to others, we can. These challenging times call for innovation. Therapy can become exactly what kids need: a safe but exciting place to be challenged to grow. In other words, an adventure.

 

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Related reading, from the CT archives: “The power of virtual group therapy during a time of quarantine

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Per Eisenman (peisenman@csac-vt.org) and Ally Bernstein (abernstein@csac-vt.org) are community mental health counselors in the Youth and Family Services Program at the Counseling Services of Addison County in Middlebury, Vermont. They have been leading therapeutic groups for teenagers using role-playing games since 2015 and 2018, respectively. At the beginning of the COVID-19 pandemic, they transitioned these groups to telehealth.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Counseling Connoisseur: Hope in action and mental health

By Cheryl Fisher February 16, 2021

Hope is being able to see that there is light despite all of the darkness. – Desmond Tutu

 

[NOTE: This is this first piece in a COVID-19 recovery series]

Without a doubt, 2020 was a challenging year. Many of us greeted the New Year with arms wide open in anticipation of better days ahead. Out with the old and in with the new. The months of isolation, social and physical distancing, masking up and suffering so many losses has taken their toll on our mental health. Public surveys and reports from mental health authorities show that rates of depression and anxiety have increased exponentially as people attempt to navigate remote work, virtual classrooms or even worse — unemployment. Election fatigue, inaugural distress and racial injustice continue to plague society. Coping strategies are restricted with the closing of gyms, places of worship and many other gathering spaces due to COVID-19. Reports of Zoom fatigue have blanketed media. People who have access to resources are reaching out to mental health providers who are also feeling the exhaustion from a year of unprecedented circumstances. My own practice has been booked months in advance, and I am turning away new client inquiries and referring to colleagues whose schedules are also full.

Yes, 2020 was a year like no other for many of us. Only time will tell if 2021 will be as chaotic, but we already face challenges such as continuing political unrest, the attack on the U.S. Capitol, the presence of new, more transmissible COVID-19 variants and the snail-paced vaccine distribution process. As we forge ahead, recovery from the trauma will take time, patience and work. Yet, there are signs of change. Glimmers of hope. Flickers of light from the shards of a very broken year.

The New Year promised a fresh start, and the appearance of the “Christmas Star” on the Winter Solstice was a beautiful way to usher in 2021. The “star” is actually an astronomical event during which Jupiter and Saturn align so closely that they look like one radiant light.

Although Saturn and Jupiter align with each other every 20 years, it has been 400 years since they were this close to each other and nearly 800 years since the “Great Conjunction” occurred at night. Some have speculated that the star described in the Bible as leading the three Wise Men to the site of Christ’s birth in Bethlehem was, in truth, a Great Conjunction. Whatever the explanation, it was a sign of hope and peace to those who followed — and the key element is they followed.

Saturn, top, and Jupiter, below, are seen after sunset from Shenandoah National Park, Sunday, Dec. 13, 2020, in Luray, Virginia. Photo credit: NASA/Bill Ingalls

Hope and mental health

As mental health clinicians, we know the importance of hope in wellness. Yet, we often forget that hope is also a verb. We create a space for hope in our sessions with our clients. We hold hope when our clients are unable.

There are three elements that accompany the experience of hope.

Having goals

Having something to work toward can provide us with structure and predictability. However, we want to craft goals that are specific, measurable, attainable, relevant, and timely (SMART). That should sound familiar to counselors. Often goals are too broad. For example, in my other life I owned an aerobic company and often provided personal training to people who attended the aerobic classes. Goal setting was an integral part of the training. At times, my clients would give me goals such as, “I want to be healthy.” “I want to be skinny.” “I want to be happy.” or “ I want to be active.” I would follow up each request with “What exactly does that mean? Paint a picture for me of what being “healthy, skinny, happy, or active” means to you? Then we would break it down into specific, manageable goals in which “being healthy” may mean running a first 5K race or being skinny may mean losing 10 pounds.

This year, one of my big goals is to celebrate my parents’ 60th wedding anniversary this summer with family face to face, even if we need to meet outdoors. I have missed my family desperately this year. However, we have family members who are vulnerable, and we have resisted gathering this year because of the risks of COVID-19. What more joyous way is there to come out of the darkness of the pandemic than by celebrating the commitment and legacy of my parents’ union together.

Feeling empowered to shape your daily life.

Envisioning the outcome of your goal is so much a part of the process. Performance psychologists have utilized imagery for decades with athletes. Imagine yourself as already attaining the goal. Feel it already accomplished.

It is also important to recognize our agency and there are times when we really do not have control over things. I like to ask myself, “What do I have control over? What don’t I have control over?” I then focus on areas under my control.

For example, I worked toward a family gathering goal with something I could control by scheduling renovations to my home during the pandemic lockdown. I now have the space to celebrate when I am able to gather with my family again.

Additionally, I have been fortunate to be included in the first rounds of the COVID-19 vaccine rollout. So, I will be fully immunized, as will be most (if not all) of my family members by summer. While I still anticipate taking precautions, there will be greater confidence in gathering.

Identifying ways to make goals happen.

Really lean into the role you play in accomplishing your goals. What steps do you need to take to achieve them? If you want an advanced degree, what is the next step? Information gathering? Taking the GRE? Applying for funding? Create a chart of the actual actions needed to be taken to achieve your goal.

As I make ready my home for celebrations and follow the CDC guidelines around my vaccine schedule and follow up protocol, I am furthering the vaccination efforts by volunteering with my local medical response corps. I am assisting in providing human resources to advance the distribution of the vaccines so that my family and community will have a better chance of achieving full immunization sooner. Check with your local agencies to see how you can promote the change you want to see. For example, senior and community centers need assistance with helplines that reach out to vulnerable populations to help them navigate the online vaccine registration process.

Hope in action requires motion. It requires feeding the flame with movement toward goals, desires, dreams. Hope is choosing to look beyond the darkness to recognize even the smallest glimmers of light and then magnifying them with our words, actions and deeds. The Wise Men saw the brightness of the star, and rather than stay in the darkness, they chose to follow the light. That is hope. Hope in action.

Let your COVID-19 recovery begin with hope in action.

 

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Cheryl Fisher

Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is director and assistant professor for Alliant International University California School of Professional Psychology’s online MA in Clinical Counseling.  Her research interests include examining sexuality and spirituality in young women with advanced breast cancer; nature-informed therapy; and geek therapy. She may be contacted at cyfisherphd@gmail.com.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

No rest for the bullied

By Laurie Meyers February 1, 2021

The climate of intolerance, anger and, to put it plainly, hate, that was encouraged to bloom during the past four years have kept Jessi Eden Brown busy as the professional coach for the Workplace Bullying Institute (WBI) and in her private psychotherapy practice in Seattle. According to the WBI, targets of workplace bullying consistently reported more frequent and more brazen attacks, crippling sabotage, and mobbing based on known or assumed opposition to the Trump administration. Brown has seen this trend playout in her private practice and in her coaching work at the WBI. In the weeks surrounding the insurgent attack at the U.S. Capitol, two of Brown’s clients reported that workplace harassment had escalated to personal property damage.

“One had, ‘Trump 2020,’ scratched into the hood of his car in the employee parking garage,” says Brown, a licensed professional counselor. “And the other told me his locker was broken into [and] the contents [were] soaked in red paint, one day after the U.S. Capitol riot.”

The division between mask-wearers and anti-maskers during the pandemic has also created a pernicious type of bullying, Brown says. “For example, one client told me that three workplace bullies have ‘fake coughed’ in her direction for months, often followed by snickering and occasional obscene gestures. She said she considered reporting the problem to HR or management, but her last grievance resulted in retaliation, so she has opted to try to ignore it and keep wearing a mask.”

The pandemic has also contributed to an uptick in bullying in other ways, Brown says. “At the beginning of the pandemic, many of my clients reported an overwhelming sense of relief as they transitioned to remote work [and were] no longer required to face their bullies in person,” she explains. “Bullying tactics such as micromanaging, nonverbal intimidation and public humiliation were dampened by distance. However, for some clients, that period of calm was short-lived, as bullies began to weaponize the very technology we rely on to work from home. Clients told me their invitations to essential Zoom meetings were ‘somehow overlooked.’ They talked about the relative ease with which bullies manipulate reports and documents, craftily overinflating their contributions and minimizing the target’s value.”

Brown’s clients have also reported feelings of mounting isolation as they face increasing levels of resource gatekeeping.

The economic collapse brought on by the pandemic is also being wielded as a weapon, according to Brown. One client’s boss regularly makes threats such as “This is not the time to be jobless, so you really don’t want to screw up next week’s presentation.”

Brown says that, understandably, most of her bullied clients fear leaving their jobs during the pandemic, despite the abuse they are subjected to.

“Sometimes there are ways to push back and advocate for yourself; other times that may only make things worse,” she says, noting that the outcome is highly situationally dependent. “I work with my clients to explore their options and refocus whenever possible on addressing their health. Setting boundaries, boosting self-care and seeking outlets for processing pain and frustration — all might help the client survive in the job until the outlook is more positive.”

“A couple of my clients have reached their absolute limits in dealing with workplace aggressors and have opted to resign, transfer or prematurely retire despite the extraordinary uncertainty of a global pandemic,” Brown continues. “One client is taking advantage of the opportunity to return to school and recast her career in a different direction. The other is taking a bit of time off, living on savings and repairing his health — knowing he has a financial cushion of exactly six months. As that deadline draws near, we will plan out the next steps and, ideally, he will reenter the workforce feeling a bit recharged and focused on creating a fresh start.”

These are difficult situations to face in counseling, Brown acknowledges, and she sometimes becomes concerned for the safety of her clients. “First, I listen to their account of the incident, allowing the client to process the fear, anger, confusion and vulnerability that comes with being persecuted,” she says. “From there, we talk about any steps — minor as they may be — to help the client feel safer.”

For example, because his house keys and wallet were in the locker when someone broke into it, Brown’s client decided to change all of his locks at home and add two more security cameras to his home system.

In cases that involve bullying that is potentially criminal, Brown and her clients discuss whether to file a police report or take any other formal action, weighing the costs and benefits of these decisions.

“I also research and pass along any specific resources that might offer additional support for my client, such as hate crime victim support groups, PTSD [posttraumatic stress disorder] groups … Unfortunately,” she says, “as things continue to deteriorate in our society, it is challenging to help these individuals fully regain a sense of safety, which is something we often recognize and address openly.”

“I have witnessed the combined effects of a divisive Trump administration, a deadly global pandemic and an intense racial reckoning precipitate enduring traumatic injuries on some of my clients. Often,” Brown concludes, “I think the repair and healing work we do in therapy is only just beginning, and even more challenging times lie ahead.”

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COVID-19 has largely redefined where people work, how people work and the workplace challenges that confront employees as they try to make ends meet. Read more in the article “Working our way through the pandemic,” in the March 2021 issue of Counseling Today.

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Laurie Meyers is a senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.