key: cord-0059003-jusamwc3 authors: Wilking, Anna title: Shared Trauma and Harm Reduction in the Time of COVID-19 date: 2020-09-29 journal: Shared Trauma, Shared Resilience During a Pandemic DOI: 10.1007/978-3-030-61442-3_11 sha: b920bd9cb9d75eb09e072904fb1cfbc02a174898 doc_id: 59003 cord_uid: jusamwc3 COVID-19 presents an unprecedented time for both clinicians and clients alike. As clinicians we experience a shared trauma with our clients as we both adjust to new circumstances. I can relate to how my clients are coping with the pandemic, particularly for those clients who have compulsive or addictive behaviors. With many of our adaptive coping mechanisms diminished, it is easy to fall back into destructive habits. During this time, I have turned inward to reflect on how my own experiences can help serve my clients. Rather than preaching abstinence, I find that harm reduction strategies, which help reduce compulsions or allow clients to engage in them more safely, are the most effective form of treatment. More than ever before, my work as a therapist is based in the tool of acceptance. Acceptance allows my clients to interrupt the cycles of shame that help feed addiction. Ultimately, this provides the opportunity to change behaviors. As I fight parallel battles during the coronavirus pandemic, I find that shared trauma provides rare moments of intimacy and connection that serve to deepen my client relationships. And although they do not know it, my clients’ examples help me to accept and heal my own behaviors. blurring of professional and personal boundaries, and increased self-disclosure in the therapeutic encounter" (p. 625). Indeed, the first thing I noticed was the abrupt disappearance of the typical distance I usually maintain during my therapeutic encounters. I had to utilize this sense of increased intimacy to enhance the therapeutic alliance while simultaneously maintaining appropriate boundaries and navigating the complexities of self-disclosure. I felt self-disclosure would be an inevitable part of treatment during Given my own struggles with food and alcohol, I have been particularly attuned to my shared experiences with patients who have tendencies towards compulsive behaviors. Quarantine has been a cruel test of our coping skills. As I have experienced my own tests during COVID-19, I have also observed some patients slip back into addictive behaviors or experience a surge in their compulsions. One patient started smoking again, after years without a cigarette, while another has gained 15 pounds due to her uncontrollable binges. Another patient has started pulling at her hair nonstop, while another has become a daily marijuana smoker. A patient who used to drink exclusively on weekends has become a daily drinker. One of my teenage patients has developed crippling insomnia, falling asleep at 6 am every morning due to her compulsive checking of social media. Another patient is experiencing an uptick in her self-harm cutting behavior. The list goes on and on. It is no mystery what is happening here. My patients are turning to these comforting behaviors to help them through our current crisis. Like me, they are revisiting "old friends," as they watch opportunities disappear to put into practice other healthier coping mechanisms. No more going to the gym or yoga classes, no more connecting with friends, no more breaks from their loved ones or for those that live alone, no visits with loved ones, no more nights out on the town, no more escape to the office, no movies, theater, or museums. Indeed, in the early days of quarantine, such was the feeling of alarm and panic that some people did not even leave their apartments for grocery shopping. Stripped of our typical adaptive strategies to selfregulate and process emotions, it is no surprise that I have seen resurgence in my patients' self-destructive habits. Another interesting factor that plays a role in the re-emergence of these maladaptive mechanisms is the concept of time and the idea that the COVID-19 pandemic has a specific trajectory, which includes a beginning, middle, and potential end, when a vaccine emerges. It is significant that my patients use the temporal arc of quarantine and COVID-19 to rationalize and justify their behavior. Patients tell themselves (and me) that they have regressed back to whatever habit, "just during quarantine", and once "quarantine is over" they will stop. A lot of individuals use crises to relapse or self-indulge, and indeed, the bell curve of COVID-19 facilitates this behavior as patients see an external marker of when they will stop. They think that they can briefly revisit self-destructive behavior because they tell themselves that it will only be temporary. On more than one occasion, I have had patients tell me their "quit date" is when COVID-19 ends. However, it remains a risky proposition. As I know from personal experience, sometimes it is difficult to stick to quit dates once back deep into compulsive behavior. Furthermore, it looks increasingly like the coronavirus pandemic will not have a clear end, so these potential quit dates have become muddled and unreliable. They no longer work as behavioral cues. In my treatment of patients during COVID-19, I have found that harm reduction strategies have been a useful clinical approach. Starting initially as a public health approach, harm reduction is typically utilized in the substance use field, in which providers help decrease the negative consequences experienced by drug and alcohol consumers and the communities within which they live (Marlatt & Tatarsky, 2010) . It includes a set of policies and practices that advocate for the dignity and empowerment of substance users, recognizing them as individuals with agency who can make choices without fear of facing discrimination or stigma based on their substance use (Marlatt & Tatarsky, 2010) . Harm reduction steps away from criminalization and moves towards treatment of substance use. It challenges views that label these individuals as "evil" or "morally compromised" (Seiger, 2014) . It recognizes the complex social factors that affect individuals' consumption patterns, their history of use, and their future potential trajectory of use, taking into consideration the challenges they might face due to positions of class, race, gender, sex, educational level, housing and food access, social supports, and myriad other issues. In the spirit of "meeting individuals where they are," the idea is to broaden the framework of assisting substance users beyond the strict confines of abstinence. Although abstinence can be part of harm reduction, it is recognized that abstinence might not be the goal for every substance user (Seiger, 2014) . As a public health model, harm reduction was perceived as a radical intervention that might not stop individuals from using altogether but could save lives in the long run, by making consumption safer. Hence, in the 1990s during the AIDS crisis, the distribution of clean needles became a successful harm reduction strategy that gained national force to help stop spreading the epidemic (Heller et al. 2009 ). Why is this approach particularly suited to COVID-19? As explored above, I had to first recognize that during the current COVID-19 crisis, my patients do not have access to many of their typical adaptive coping strategies, like socializing or going to the gym, and, as such, will turn to self-soothing by any means necessary. Maladaptive coping mechanisms are still coping mechanisms, even if they can be self-destructive in nature. It is not my job to strip my patients of the only ways they know to cope through crisis. It is my job to guide my patients in developing skills that will promote their well-being and mental health. However, I recognize the need to approach the emergence of maladaptive behavior with the therapeutic tool of acceptance. Indeed, at the core of any harm reduction strategy is the notion of acceptance and a withholding of judgment in order to prevent patients from falling into cycles of shame. Shame is often the engine fueling addiction. Flanagan (2013) points out that "shame is partly constitutive of addiction…[the addict] is appalled by the twin normative failures from which he suffers, and shame is the appropriate, respectful, humane, first-person response to these failure" (p. 8). Substance users fail to adhere to not only their own moral code but also the social norms set by wider society. None of my patients who have reverted back to self-destructive compulsions are proud of their slips backwards. Often they are frightened by their behavior and feel out of control. I can relate to such fears. They do not reveal their behaviors to me immediately, and some have only recently mentioned them as desperate confessions because they do not want to slide backwards further. In all of my cases, the overwhelming feeling that comes forth again and again is shame. They view their compulsions as the darkest part of themselves, often buried beneath layers of secrets and deception. They are ashamed because they know they are hurting themselves, despite "knowing better." They are just as baffled as their loved ones are as to why they continue their self-destructive behavior. As they continue to act against their values and moral code, they feel greater and greater shame. But that is the nature of compulsion and addiction more widely-the continuation of use despite mounting negative consequences. According to Flanagan, the cycle of addiction can only be broken by "overcoming shame" (2013, p. 8). I argue that one way to overcome shame is through acceptance. Countless treatment strategies have incorporated ideas of acceptance into their toolbox, including various behavioral therapies, mindfulness, and perhaps the most widely known-as the cornerstone of 12-step programs like Alcoholics Anonymous. Acceptance in 12-step programs is best illustrated by the Serenity Prayer in which participants "accept the things they cannot change." The power of acceptance rests in its reframe, in which we surrender to our reality instead of resisting or fighting it. Such surrender often pushes us to seek help outside of ourselves, as we can finally admit that we cannot stop our insane behavior alone. Acceptance removes judgment and allows for clarity and, ultimately, a path forward. As therapists, it is our job to accept our patients as they are. They might come to us broken and emotionally fragile. We recognize their innate value as humans and empower them to help reframe cognitive distortions and make self-serving decisions to improve their lives. When patients finally work up the courage to share their concern about the re-emergence of a self-destructive habit, it is imperative that I refrain from alarm or "scolding" and provide the gentle reminder that it's ok, that they are doing the best under the current crisis, and that it is only natural that they are revisiting practices that they once found so comforting. Indeed, I would be highly surprised by any therapist who would take a punitive approach towards their patients after they have shared such vulnerability. Furthermore, my patients have only been able to share their compulsions with me because we have already established a therapeutic alliance based on trust and security. Just the fact that they can divulge their darkest secrets is a testament to the strength of our relationship. The power of acceptance lies in the validation of my patients' worth. It is a powerful antidote to the self-loathing that accompanies compulsion. Once a patient can move into acceptance of the behavior-guided by my acceptance first-the overwhelming feelings of shame can be minimized in order to allow other coping mechanisms to emerge. It is a relief that often a simple reassurance to my patients that they are ok-that a slip during the COVID-19 crisis does not mean a lifetime of imprisonment-acts to open up the necessary dialogue to examine the behavior more closely and to do the work to prevent it from continuing. Patients want to know that they are ok at their core and that they have value and are loveable regardless of their slips. Once acceptance has been established, I next work with my patients to apply the practical principles of harm reduction on a case-by-case scenario. I do not push for complete abstinence of their behavior overnight, but rather set gradual goals to ease the transition from maladaptive thoughts and practices into healthier ones. This works to empower my patients in order for them to see improvement in their behavior to open the door to further recovery. For instance, in the case of my patient who has started smoking again, we have established a plan that simply reduces her number of daily cigarettes. My patient who struggles with binge eating is stocking her fridge with healthy options. She is also reducing the number of hours of Netflix she watches at night, as that is a major trigger. My patient who pulls out her hair is trying to reduce the practice to a certain restricted time, instead of feeling the urge to pull all day. The daily marijuana smoker is reducing the days he smokes and the daily amount. My patient whose drinking has escalated is not drinking hard liquor and must interrupt his rapid consumption by involving himself in another activity between drinks. My teenage patient who is addicted to social media has her parents take away her phone a half hour earlier each night to reduce her access. My patient who engages in self-harm uses other things to replicate the results and sensation of cutting-she snaps a rubber band on her wrist often to the point of dire pain, but yet she has put down her sharp objects. These tactics have prevented patients from feeling the sudden panic of removing their deeply comforting coping skills. It creates a gentle transition in which they see the slow reduction of the behavior, which in turn empowers them to continue on an upward trajectory. I experience the shared trauma of COVID-19 with my patients. However, I was not expecting to share the trauma of dipping back into battles of compulsion. More than ever before, I identify with these patients' struggles. Although I have refrained from sharing specifics, I have found that self-discourse about experiencing "slips" into compulsive behaviors has been deeply soothing to my patients. I do not have to share the details of my story; anyone "in the know" can immediately identify that I am "one of them" simply by the language I use to describe the emotional turmoil of addiction. They are relieved that I understand and rejoice in knowing that their therapist is a flawed human as well. Self-disclosure becomes another tool in breaking down the wall of shame, as they can now connect to someone who knows addiction/ compulsion intimately. The silver lining of COVID-19 is that I have learned to connect to many of my patients in a new way. I had anticipated that we would share similar anxieties about the trajectory of the virus or adapting to new routines, but it had not occurred to me that I would face parallel battles against compulsive behaviors. This type of shared trauma creates a unique intimacy that has strengthened and deepened my client relationships. I know that in my own transition back to self-regulation, I must apply my own advice. 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