key: cord-0818887-on5qqox2
authors: Ledesma, Dana Angelica S.; Fernandez, Karina Therese G.
title: ‘If I am not well, I can’t do sessions well’: An analysis of the narratives of Filipino Therapists during the COVID‐19 Pandemic
date: 2021-07-09
journal: Couns Psychother Res
DOI: 10.1002/capr.12442
sha: 6f38117461e0835633bce2805d54a38b1edcdb81
doc_id: 818887
cord_uid: on5qqox2

Research is uncovering the repercussions of the COVID‐19 pandemic on the mental and emotional state of various populations around the world. It is of particular interest to this study to explore how the pandemic has affected psychologists conducting therapy with clients in distress during this time. A qualitative approach was used to analyse the narratives of eight Filipino psychologists who were living in community quarantine while conducting therapy from March to December 2020. The results revealed four chapters: (1) ‘thrown up in the air’, (2) struggling to find their footing, (3) gaining stability and (4) ‘finding new rhythm’. It was found that these psychologists suffered the emotional distress from the pandemic that many are experiencing around the world. They needed to first regain stability in their well‐being before being able to become effective helpers to their clients again. Moreover, they eventually found new purpose and growth in their practice. This study documented and discussed the journey of therapists in a shared traumatic reality, from first exposure to growth.

and being able to find meaning in work allow for resiliency and prevent burnout.

Studies on resilient therapists have also pointed out the importance of being self-aware when working with clients in crisis (Ling et al., 2014; Russo-Netzer et al., 2020) . These therapists remain mindful of problems in their personal life and distress that come about during therapy in order to resolve and correct them when they arise. They also find it pertinent to acknowledge their own limitations within therapy, knowing how to meet the needs of their clients while still sustaining their energy for themselves. This selfawareness overlaps with self-care practices, in that therapists need to be attuned to their own needs in order to care for themselves.

Self-care, as outlined by several studies, includes setting boundaries between their lives at work and at home, drawing support from both personal and professional relationships and practising selfcompassion (Barton, 2020; Clark, 2009; Ling et al., 2014; Roebuck & Reid, 2019; Ronnestad & Skovholt, 2003; Tyskø & Lorås, 2017) .

The pandemic is a unique context for psychotherapists as they are in a shared traumatic reality with the client (Baum, 2014) . That is, they and their clients are being confronted with a traumatic event that is affecting the community they are both living in. Having the pandemic in the background of daily life and therapy work may result in additional pressure and psychological distress in therapists, challenging them to continue giving effective care to their clients.

Handling clients who share their concerns may demand more resources from the therapist to overcome their personal concerns to address the needs of their client, making them vulnerable to burnout.

• This study highlights the need for assessing if mental health workers are equipped with the internal resources needed to conduct therapy during a crisis. It is also crucial to normalise the experiences that other mental health workers may go through, as they struggle to have effective sessions when they are still grappling with the crisis situation themselves.

• This study hopes to help other therapists make sense of their experiences during this pandemic. It may also help therapists of therapists to see in what state their therapist-clients may be according to the chapters identified in this study. In doing so, they may also use appropriate interventions according to what their needs are.

• Training and supervision of therapists may need to be evaluated to better support mental health workers during this pandemic and future crises. This study will benefit supervisors and managers of clinics to effectively support their therapists, such as managing their workload or in assigning cases depending on what chapter they perceive the therapist to be. Additionally, in training, knowing the experiences of being in a shared traumatic reality will help prepare student therapists who will be starting their careers during this pandemic and/ or may experience a similar situation in the future.

Additionally, this study took place during quarantine, where Filipino psychologists were conducting therapy at home and were isolated from extended family, friends and colleagues, making it difficult draw support from others. Furthermore, working from home also created difficulties setting boundaries between work and personal life.

This study wishes to extend the existing body of knowledge by understanding the experiences of therapists during the COVID-19 pandemic and how they unfolded. Therapists are taking on the burden of responding to the growing mental health crisis, but it is yet to be known how they themselves are experiencing and coping with the pandemic, as well as how they are facing the new kinds of challenges brought about by conducting therapy at this time. It is particular to this current time in history that this study be done as it captures a global experience where both clients and therapists are exposed to common factors that may induce trauma, anxiety or fear.

One way to set the stage to understand the meanings, challenges, feelings and experiences of psychologists who, along with their clients, are embedded in a very challenging context is to ask the question: What is the story of Filipino psychologists conducting therapy in the midst of the COVID-19 pandemic? In answering this question, this study will take an inside and in-depth look at the journey of Filipino therapists during the current pandemic and how they are navigating and making sense of their experiences.

Eight licensed psychologists who had been conducting therapy during the pandemic were recruited for this study. Their ages ranged from 28 to 35 years old. Two participants were married, and one participant had children. All the participants were engaged in a group clinical setting and were quarantined in the city. The average number of therapy hours conducted by the participants per week ranged from five to thirty-two hours.

This study received ethical approval from the Ethics Office of the investigator's university. One-on-one interviews were conducted online by the first author over Zoom throughout December 2020 and early January 2021. Participants were asked to narrate their experiences of living in, and conducting therapy during, the COVID-19 pandemic. The first author did not impose a starting point for their narratives and left it to the participants to decide when their narratives began. After they shared their story, they were asked to recount their experiences as if chapters in a book and to give a theme for their whole experience. They were also asked to reflect on their experience of being a therapist in the pandemic.

In order to analyse the data from the interviews, the study was guided by the steps for narrative analysis according to Murray (2015) and Lieblich et al. (1998) . First, familiarisation with the data was done by re-reading each participant's interview after transcribing the recording. A short summary of each narrative was made to highlight the different events of the stories and understand the narrative as a whole. Doing this allowed the authors to identify similarities and differences among the different narratives in order to draw out a shared plot. In understanding the broader plot and common themes across the participants, the authors identified patterns in how the plots developed, while being mindful of the uniqueness of each participant's story. Additionally, the author focused on the themes that highlighted the inner experiences of the participants.

The results revealed four chapters in the shared narrative of the participants. This section will contain a detailed discussion of each chapter to describe how the chapters manifested in the participants' mental and emotional state. This paper will use 'pandemic', 'quarantine', and 'lockdown' interchangeably, as it was apparent in the interviews that the participants used these three terms similarly.

As the news of the quarantine had spread, the participants became unsure of what living in a pandemic would be like and perceived it as temporary, minimising the effects of the quarantine on their lives. Shortly after, with the continuous extension of the quarantine, they began to see that the pandemic was not an interim event.

This realisation created a heavy emotional effect on them as they began to face an unfamiliar time when their normal lives had suddenly been disrupted, where 'everything was thrown up in the air'.

This chapter was particularly emotional for the participants, as they did not know how to cope and make sense of what was happening. There were a lot of questions about how to go about their daily lives.

The emotional and mental effects on the participants in this chapter were comparable to the normative experience of fearing the COVID-19 virus and grieving the loss of normalcy that many around the world had felt when the pandemic first broke out. As such, the focus of their attention at this time was on experiencing the pandemic on a personal level rather than professional, as they feared how the virus would affect them and their families and were focused on how they could cope with the loss of their routines. During this period, their view towards their therapeutic work was a means of earning a living. They looked at their work at this time more as a wage earner than a therapist. One participant shared: 

For all the participants, this chapter was characterised by feelings of high levels of personal anxiety, fear and paranoia about being infected with COVID-19. Since most of the participants live with family, there was also a sense of fear of bringing it home. Being faced with the unfamiliar nature of the virus, they were also more anxious to find new information and regularly tuned into the news to receive updates, which contributed to their stress. As one participant put it, 'I was also experiencing anxiety myself. On a personal level that was hard to accept'.

When the lockdown in Metro Manila was implemented, the participants' routines of going to work, socialising and leaving their homes were put to a halt. For many of the participants, this resulted in feeling sad, frustrated and suffocated. Having to abruptly adjust to the new and unfamiliar situation, the participants found it difficult to get their bearings and settle into the new routine of being confined at home. Having to cope with the new set-up of the lockdown took an emotional toll on the participants and left them with less energy and resources to be able to work, especially in conducting therapy. Lost along with their routines were their usual coping strategies, such as being outdoors, dining with friends and debriefing with colleagues.

As therapists, their work was also cut down as many, if not all, of the participants' clients chose not to transition to online therapy at the time. Two participants expressed how this also incited some anxiety over their finances, not knowing whether clients would eventually come back. Other sources of work, like teaching and conducting workshops, were also suspended at this time. Overall, the participants felt aimless. Because their busy routines had suddenly been taken away, they had so much time on their hands but did not know how to manage it.

Whereas many of the participants in the first chapter were thinking, 'How do I cope with the pandemic?', in this chapter, the participants began to think 'How do I do therapy in a pandemic?' The participants began widening their spotlight of attention from focusing only on themselves to also focus on their clients and slowly began to conduct therapy again. However, the participants found it particularly challenging to work at this time, despite having fewer clients compared with their pre-pandemic workload. The previous chapter put them in an unstable emotional and mental state, making this chapter a difficult time for the participants. In addition to the demands that therapy requires of the therapist, much of their energy was also spent on adjusting to the new logistical and technological challenges that came with online therapy. As one participant put it, she struggled to find her footing again when it came to the work.

During this time, the participants were finding that they were unable to do the same amount of therapy that they were doing before the quarantine. They asked to stop receiving new clients in order to manage the transition to online therapy with their current clients and mentioned dreading the work. They were still trying to cope with living in quarantine, making it difficult to have energy for other aspects of their life, especially therapy.

Personally, I couldn't be in the right headspace to meet clients just yet, so I didn't want to take on more 

Having to do therapy from home was a difficult adjustment for all the participants. They expressed feelings of frustration and helplessness, because of all the adjustments needed just to continue working. For some, there was also a sense of anxiety because of the unfamiliarity with how to conduct therapy online and how to use online video calling platforms efficiently.

Since most participants lived with others, they had to negotiate for private space to do therapy and needed to buy additional equipment to help the client feel that the therapeutic space, though now online, remained safe and confidential. Having to make all these arrangements was also a source of stress for the participants; however, given the urgency to make online therapy more comfortable for clients, they were pressured to learn to manage these arrangements quickly.

The participants also mentioned that being in a different physical space to the client made it difficult for them to gauge their clients' nonverbal cues and the therapeutic atmosphere of the session. This, coupled with unpredictable and intermittent internet connections, made it difficult to have conducive environments for therapeutic sessions. Having to be mindful of all these adjustments took more energy from them and made it more challenging to be fully present with the client.

We have to try harder to connect … When it's online, … you have to do more things to be more present. I noticed myself, either I'm clenching or I'm more tense, so it takes a bit more and it's a bit more tiring to do.

There was a sense of frustration among some participants with how online therapy can feel limiting for the kind of techniques they can use. As one participant put it, 'It's so different. There are things that I usually use, techniques in therapy that feels different when done online, and things that I cannot do online. Like … projectives. I usually do cards to help clients'.

Lacking this private space at home also made participants feel 'homesick' for the clinic. Being in the lockdown made them realise how having different offices and physical spaces for different parts of their life (e.g. clinic for therapy, school for classes, mall for errands and shopping) was helpful in compartmentalising their life. Now having all those different areas of their lives sharing the same physical space at home, participants found it difficult to get themselves to work and focus on one thing. Having to do all their work from home made them feel physically limited, as they were tied to their screen all day.

Limitations were also felt in that the participants could not have the social support they used to have from their colleagues. They reminisced about debriefing between sessions and discussing their cases with their co-therapists. Though they knew that their colleagues were only a phone call away, they also acknowledged that their colleagues could also be having a tough time adjusting, so they did not want to burden them with what they were going through.

Having to find a way to debrief on their own, especially after heavy cases, was a tiring task.

If you have a question or you have an idea, you can just bounce it back with some other psychologists' brain. But now I'm the only psychologist in the house, so I don't have anyone to talk to. Other people won't understand. They don't have the same-because they don't have that experience. So, if you tell it to another psychologist, they'd get you and they'd get you at a deeper level.

The participants observed a sense of novelty in doing therapy as they were personally going through the same experiences as their client at the same time. The participants felt worried about how they would face clients when they themselves were still trying to make sense of the pandemic. There was an added pressure to manage their own emotions towards the pandemic when hearing their clients' stories. For some participants, this made it difficult to manage the mental demands of therapy and separate their personal issues from the clients' during sessions.

There was a common experience between us which is the experience in the pandemic and the challenges that go with it. Normally the clients are going through something that you are a witness to it, but you're not really going through it. And that's part of what I have to manage also.

Having to manage their emotional well-being, seeing clients and adjusting to working from home took a toll on many of the participants.

This eventually led to them feeling tired and burned out, which affected them both professionally and personally. As one participant put it, 'It was like, "I don't wanna do this." And my friend asked me, "Let's catch up on Zoom." Like even therapist friends? And I'm like "You know what, no. I don't want to. You're tired."' Their energy and internal resources were at such a low level that even the activities that used to recharge them before the quarantine felt draining.

There was a time when there were so-I was seeing so many clients, and so many intake sessions that I had to stop myself and say, "Wait, wait what is going on? You're taking so many clients now and you're feeling so tired already". So, I'm sensing that I'm getting emotionally and physically tired of the work.

The third chapter is characterised by most of the participants starting to feel that they became more adjusted to living in the pandemic.

At this point, the emotional levels in the first and second chapters settled to a more manageable level. Before this chapter, living in a pandemic was at the forefront directly affecting their experiences; however, from this chapter onwards, the pandemic receded into the background and became more of a context they were living in.

The participants attributed being able to gain stability amidst the uncertainty of a pandemic to having set routines and scheduling.

Though they were unable to regain the routines they had in the past, having a new routine helped them to feel comfortable living in the pandemic and gain a sense of certainty in what would happen in their day-to-day life. In the second chapter their usual routine was disrupted and left them wandering aimlessly, but having a routine again offered them a sense of control.

After the previous chapters, where they experienced feeling drained and burned out from doing therapy, the participants realised that they needed to find ways to continue working while giving them the space to care for themselves. This took some experimentation and trial and error in discovering what worked for them. Many of the participants mentioned scheduling specific days for therapy.

For some, it also meant scheduling breaks between sessions to help them prepare mentally and emotionally for the next client; this was particularly new for many of the participants, as they felt that they had to make more effort in the pandemic to check-in with themselves and ensure that they were not exhausted.

In order to cope emotionally with the pandemic while continuing to do therapy, the participants discovered what it really meant to practise self-care. For many of the participants, the pandemic was a wake-up call to be more attuned with their emotional well-being.

Because they also lost access to their pre-pandemic coping strategies, the participants had to find new ways to cope.

For some participants, this also meant having to take more breaks from therapy, which they were not used to doing before. Having to take breaks more often was difficult to accept at first, but they also quickly realised how much they needed it in order to continue working. One participant realised that 'If I am not well, I can't do sessions well. And I don't want that to happen'.

Participants also mentioned needing to apply to themselves the different techniques they would advise to their clients in therapy in order to cope. Because of the anxiety they felt towards the pandemic and being in quarantine, they needed to practise mindfulness or grounding exercises. Some would also try to reframe the situation in order to make better sense of it. In some ways, the process and exercises they were doing with their clients at that time were not only therapeutic for the client, but also for themselves; having to advise clients to practise those exercises served as a reminder that they needed them too.

You use strategies with clients. You tell them things they could do and most of them have anxiety as well so you're like, 'How are you able to tell them but I can't apply them to myself?' I had an 'aha!' moment. 'Okay you're anxious. Admit it that you're anxious yourself' and that you kind of have to do some mental work too, like CBT on yourself, do mindfulness, do grounding techniques because you also need it.

Notably, participants found a shared feeling of comfort in discussing the pandemic in sessions with their clients, as it helped the participants process what was happening to them as well. Because of the understanding between them and the client that they were in the same situation, the participants felt that some self-disclosure would be helpful in empathising with the client and normalising what the client was going through. One participant explained.

I think it helps them to know that. … It's a therapeutic pull, normalizing. So, you normalize it in general.

Everybody is going through that now and so they also know [that you're part of] 'everybody'. Because nobody knows how to navigate a pandemic.

It was after establishing a routine and finding a set of coping strategies that the participants began to regain the mental and emotional energy to take on their regular load of clients, as well as accept more work such as teaching and conducting workshops. Having busier schedules also made the participants feel a semblance of their pre- Concurrently, there was an influx of people seeking online therapy; the participants believed that it was because the effects of the pandemic had begun to sink in for the public and people were more ready to process it. Now that they could cope better and had regained balance in their mental and emotional states, they also felt ready to take on the rising demand for therapy. As one participant said, 'I also missed clients back in April and May where there were barely any, so when they started coming in, I was willing to take them'.

In addition to having been able to adjust and find stability, several participants found that they had reached a point where their practice had transformed and expanded, changing the way that they used to do the work. As therapists, they were finding more ways to grow, and with time on their side, they looked for ways to be able to learn more and serve more clients.

While other participants continued to struggle and feel frustrated with doing therapy online, several participants began to embrace it.

Whereas before they had felt limited, they had now learned how to adjust better to online platforms, which empowered them and reassured them that therapy sessions can continue to be effective.

After going through the previous chapters, the participants found that they felt more fulfilled when doing therapy and focused more of their time on it during the pandemic. They gained a different attitude towards online therapy that made them feel more engaged in the work and drove them to help more clients. In their eagerness to do more therapy, they were motivated to learn more about other therapy techniques and sharpen their skills to have more effective sessions. As one participant shared, I started seeing more clients and focusing more on learning, watching videos on techniques, attending webinars. [I realized that] I do wanna do counseling in this online setting. I love it.

They also found new ways of conducting therapy in this medium; though online therapy had taken away nonverbal cues and interpersonal connection, they found other ways to compensate for those limitations; as they learned to use different ways of questioning and new techniques, the way they would do therapy changed altogether. Before the pandemic, participants used energy to pay attention to the therapeutic environment and the client's nonverbal cues; now, they refocused this energy to engage the client more in the therapeutic process by being more explicit in their use of verbal skills: 

The participants felt relief in realising how being able to practise online from their homes could be convenient rather than challenging.

They talked about not having to commute to work or from clinic to Additionally, online therapy exposed them to a wider range of clients, as they observed a change in the profile of the clients that they worked with. This empowered the participants as they felt that they were able to help more people coming from different backgrounds, which they would not have been able to do had they been limited by the location of their clinic.

Having taken a step back from therapy and other work and responsibilities in the months prior, the participants also felt a desire to make up for that lost time. They were beginning to see the effects of the pandemic on the mental state of Filipinos and began to realise a new purpose of helping more in their community through therapy. They found themselves accepting more clients of various backgrounds, offering discounts to those who could not afford regular sessions and even giving free workshops. Recharged with new energy as they were becoming more engaged in their work, they felt a greater calling to help more people beyond the clients they would receive in therapy. As one participant shared, Not everyone has the privilege of support. So, I feel like it more than ever [the pandemic] highlights the need to have this accessible and we really need to reach out to the communities, to workplaces, and make this service [therapy] available to everyone.

Along with the expansion and transformation of their practice, there was a sense of hesitation from these participants to go back to having therapy in an offline, clinic setting. They attributed the growth of their practice as a benefit that came with online therapy, and they were not sure how their practice would be affected once their clinics decided to have face-to-face sessions again. Because many of their clients were now in farther areas, they also did not see their practice being as sustainable when taken offline. Additionally, having to return to commuting to and from work may mean less time for clients. In this sense, there was a reluctance to go back to normal and having to adjust to face-to-face therapy again after embracing online therapy. 

The current study presents detailed descriptions of the experiences of therapists during a time of crisis. The chapters of their pandemic story cover the challenges, reflections and opportunities for growth they underwent over the span of nine months. The findings bridge together the literature on shared traumatic reality and posttraumatic growth (Tedeschi & Calhoun, 2004) . This study extends past studies on mental health workers in a shared traumatic reality (Baum, 2014 (Baum, , 2021 Lavi et al., 2017; McTighe & Tosone, 2015) by offering a richer documentation of their experiences over a long-term period of crisis, allowing one to see how they manage the personal and professional demands of therapy. Furthermore, it highlights the opportunities for professional growth in this given context.

The findings also highlight the struggle that therapists undergo as they attempt to conduct therapy when they themselves are emotionally and mentally preoccupied and are in crisis. It was evident in the first chapter that the participants were personally affected by the pandemic and encountered the emotional and mental experiences normative of the COVID-19 pandemic. The second chapter in particular highlights the demands of therapy on therapists, as it requires them to be aware of their emotions while also holding space for their clients'. Within the context of the pandemic, having to handle these emotional demands became more difficult because they also had to adjust logistically to continue this kind of work in an online space.

The findings showed that being in crisis on a personal level made it difficult for the participants to be present with their clients. This is similar to the findings of Day et al. (2017) , who found that clinicians who are in the shared traumatic reality with their clients 'struggled to regain personal and professional balance' (p. 273). Clinicians need to address their own concerns first, to avoid confusing their own stories with their clients'. Much of the distress and emotional instability came as a result of their loss of normalcy.

Consistent with the literature on shared traumatic reality, the participants in this study were unable to fully attend to their clients and experienced lapses in empathy for their clients (Baum, 2014) .

It has been found that many practitioners feel that they are unable to become emotionally available to their clients, and as a result, they become self-critical and neglect their own emotional needs (Baum, 2014) .

The results of this study also showed that though conducting therapy during this time was difficult, the participants found it therapeutic, which aided their journey towards stability and growth.

Having this shared experience deepened the rapport with the client and allowed for more self-disclosure from the therapist to normalise the situation, similar to the findings of Shklarski et al. (2021) and Tosone (2011) . This allowed the participants to process their own thoughts and feelings towards the pandemic, affirming the findings of Folkes-Skinner (2016).

This study observed that it was paying more attention to their self-care through various practices and therapeutic techniques that enabled the participants to regain some level of mental and emotional stability. As a result, the participants were able to improve their well-being and give more attention to their clients. It was in engaging in self-care practices that the participants were able to manage their emotions and grief over the sense of the normalcy they had lost in the pandemic (Bertuccio & Runion, 2020) .

Similar to the study of Peled Avram et al. (2021) , it was also in being able to move into their role as therapists and exhibiting personal control over their routine that they were able to gain certainty and emotional stability. These findings are also confirmed by Baum (2021), who found that being able to re-establish control is crucial for mental health workers in a shared traumatic reality, as it gives them a sense of certainty in an uncertain situation. The current study extends the findings of Peled Avram et al. (2021) as it documents and details the process of therapists moving from the victim to helper role, as seen in the progression from the second to the fourth chapters.

The growth that the participants experienced may be further discussed through Tedeschi and Calhoun's (2004) model of posttraumatic growth. The results of this study show that the participants went through a challenging period of making meaning of the events in the pandemic, as they tried to find new ways to process their emotions and cope with change and uncertainty. It was particularly notable in the second chapter that the participants were met with the challenge of trying to integrate the new schema of living in a pandemic, which changed their perspective on the traumatic situation which then allowed for the third chapter of finding stability.

As a result, they experienced growth in the fourth chapter, which manifested in several domains but especially in the way they work as therapists. They were able to be more emotionally vulnerable and aware with their clients, which allows for more meaningful therapeutic relationships; have a new sense of purpose towards helping others; and were energised by the new possibilities that working through online therapy can offer (Tedeschi & Calhoun, 2004) .

This study highlights the need for assessing if mental health workers are mentally and emotionally stable and equipped with the internal resources needed to conduct therapy during this crisis. It also shows that there are opportunities for growth even within these traumatic times. Throughout their stories, participants continued to value being able to provide effective care for their clients, which also helped them to find stability and meaning in this uncertain situation. This study hopes to be able to shed light on the events of the past year experienced by these participants and help others make sense of their own experiences. Additionally, there are implications for training and supervision of therapists, given the needs and issues shown in the different chapters. Overall, this study highlights the importance of being self-aware of one's well-being and taking appropriate steps in caring for oneself, and concludes that challenging contexts create movements towards growth and transformation.

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