key: cord-0908357-74en8bkt
authors: Bell, Chance A.; Crabtree, Sarah A.; Hall, Eugene L.; Sandage, Steven J.
title: Research in counselling and psychotherapy Post‐COVID‐19
date: 2020-07-03
journal: Couns Psychother Res
DOI: 10.1002/capr.12334
sha: 13c059f9bfb36bd8eb1d555c29a1dc8311a6f6d5
doc_id: 908357
cord_uid: 74en8bkt

The COVID‐19 pandemic brings to light many areas the field of counselling and psychotherapy may need to address in future research. We outline several issues stemming from or exacerbated by the pandemic and offer suggestions for future research to address the mental health needs of those impacted. Our suggestions focus on five domains: (a) the health and well‐being of helping professionals, (b) the infodemic, (c) discrimination and minority stress, (d) spiritual and existential dynamics in mental health and (e) couple and family stress and resilience. We aim to provide a multi‐systemic perspective of mental health and well‐being in the time of COVID‐19, as well as encourage current and future studies to incorporate these suggestions to advance the health and well‐being of our communities through evidence‐based treatment approaches.

Counselling and psychotherapy transformed almost overnight after most countries around the world imposed restrictions on public gatherings to reduce the transmission of COVID-19. Many clinicians have moved their practices to a telemental health format and have worked with clients on unique issues arising from the COVID-19 pandemic. News outlets and public health agencies reporting on the widespread mental health impact cite concerns of heightened stress, fear and loneliness (Lynch, 2020) as well as increased alcohol consumption (Cramer, 2020) . The surge in mental health issues impacting nearly every domain of lived experience will require research addressing the unique issues stemming from COVID-19. The current paper utilises a systemic framework on mental health based on the assumption of reciprocal influence between individuals and their multi-dimensional relational and socio-cultural contexts. We offer suggestions for future psychotherapy research in five inter-related areas profoundly impacted by COVID-19: (a) the health and well-being of helping professionals, (b) the infodemic, (c) discrimination and minority stress, (d) spiritual and existential dynamics in mental health and (e) couple and family stress and resilience.

Frontline healthcare workers face unique challenges: increased infection risk, serving as the sole caretaker for many patients or the last person with the dying, rationing resources to patients in need, balancing personal and patients' health and well-being and navigating duty to patients and family members (Greenberg, Docherty, & Wessely, 2020; Zheng, Lee, & Bloomer, 2018) . These challenges existed prior to COVID-19, but their frequency and intensity have increased dramatically. Such burdens may lead to moral injury or mental strain originating from actions, or lack thereof, that run counter to personal values (e.g., morals, ethics), increasing the risk of mental health challenges such as depression, anxiety, posttraumatic stress, guilt and suicidal thoughts (Greenberg et al., 2020) .

The potential for these evidenced effects to be amplified as a result of COVID-19 warrants empirical attention. Although researchers

The effects of the infodemic, a phenomenon impacting public health efforts during COVID-19, are salient to clinicians and deserve empirical attention. The World Health Organization defines an infodemic as "an over-abundance of information-some accurate and some not-that makes it hard for people to find trustworthy sources and reliable guidance when they need it" (WHO, 2020, p. 7). Waves of misinformation about COVID-19 have been associated with a lack of proper social distancing behaviour, strained mental health, increased hate crimes and even the unnecessary loss of lives (Jones, 2020) .

Indeed, future research should assess the holistic impact of misinformation on mental health and overall well-being.

The current infodemic raises concern about clients who irregularly access or are resistant to accurate and current recommendations, which may put themselves and their families at risk. Some resistance to safety practices may be rooted in religious and/or political beliefs.

However, one study demonstrated that a functional fear of developing COVID-19 predicted safety recommendation adherence (e.g., social distancing, increased hand washing) while moral and political beliefs did not (Harper, Satchell, Fido, & Latzman, 2020) . Future studies should identify reasons for perceived resistance to recommended safety measures and potential strategies to balance individual and community needs. Conversely, information about safety practices may contribute to the development of extreme safety behaviours (e.g., excessive hand washing) stemming from obsessive/compulsive tendencies, especially when re-entering social life. However, we agree with Harper et al.'s (2020) suggestion to "consider the context within which negative emotional states are experienced before considering whether such emotional states are necessarily pathological" (Conclusion, para. 2). We recommend researchers investigate the beneficial role of functional fears and identify promising practices to promote emotional self-regulation and address existential fears.

Research should also address the importance of accurate health information for how safety guidelines are internalised or on individuals' capacities to think critically about recommendations from unreliable sources. Studies might also focus on treatment strategies for clients who become dysregulated by conflicting views on health practices in ways that intensify interpersonal difficulties.

Misinformation has also contributed to increases in hate crimes, particularly for Asian and Pacific Islander (API) communities, in part since U.S. President Donald Trump began using the term "Chinese virus" instead of "coronavirus" (Kim, 2020) . The U.S. state of Oregon indicated hate crimes increased by 366% in the spring of 2020 with about 20% of all reported incidents involving Asian and Pacific Islanders (Wilson, 2020) . The UK has also seen an approximate 20% increase in hate crimes against API communities since COVID-19 began (Grierson, 2020) . The Federal Bureau of Investigations warned law enforcement agencies around the United States of the potential for increased hate crimes against groups associated with the spread of the coronavirus (Campbell, 2020) .

The extensive and negative impact of minority stress on marginalised groups (e.g., overt discrimination like hate crimes) is well evidenced and deteriorates health and well-being at individual, couple/ family and community levels (Meyer, 2003) . Researchers will likely see an increase in racial minority stress and related physical and mental health impacts. Carter, Lau, Johnson, and Kirkinis (2017) noted racial discrimination likely affects health, and over and above physical health or cultural outcomes, mental health warrants particular attention.

Other minority groups have experienced unique stressors stemming from COVID-19 as well. Lower-income families, disproportionately families of colour, have had to navigate online learning without proper Internet service necessary for children's education. One in five Boston public school students have not logged in to their school accounts since March, and many are expected to be from lower-income communities (Toness, 2020) . Persons experiencing homelessness face constant exposure and increased safety concerns as many homeless shelters and resource centres have closed. A disproportionate number of homeless youths are LGBTQ, many of whom are considered extremely vulnerable in this pandemic (HRC, 2020) . Other LGBTQ youth have been forced to quarantine in homophobic environments without reprieve through school or social activities (HRC, 2020) . Research on specific clinical strategies to treat minority stress-induced mental health issues remains limited, and future investigations should focus on the translation of this research into practice. Further, evidence-based community interventions are needed to eliminate stigmatisation and discrimination towards minority groups (including youth) and to provide needed information that can simultaneously inform needed policy changes and mental health interventions.

The COVID-19 pandemic is generating massive and complicated dynamics of suffering and loss that may intensify the need for clinicians to address spiritual and existential dynamics in psychotherapy, as clients struggle with tragedy and uncertainty that can challenge prior belief systems or prompt stronger seeking within their meaning systems. Captari et al. (2018) conducted a meta-analysis showing spiritually and religiously adapted psychotherapies tend to be as effective as other secular psychotherapies and more effective for spiritual outcomes. However, psychotherapy researchers might explore ways spiritual and existential dynamics uniquely emerge in this context of global destabilisation and loss. For example, there is growing evidence that spiritual and religious (SR) struggles with the sacred (e.g., doubt, anger at God or the Sacred, absence of meaning) are relatively common but can be linked with mental health problems (Pargament & Exline, in press) and predict difficulties in psychosocial functioning (Sandage, Rupert, Stavros, & Devor, 2020) . Future studies might track SR struggles during the course of psychotherapy to see whether (a) reducing these struggles predicts unique variance in treatment outcomes and (b) certain intervention strategies might be particularly efficacious with clients who score high in SR struggles.

Existential struggles include a diverse set of anxieties about existence and human finitude that can apply to clients with or without SR commitments. Death anxiety is the ultimate existential struggle, and traumatic events such as COVID-19 can activate ongoing fears about mortality. Symptoms of PTSD and other anxiety disorders can be associated with a variety of existential concerns, including anxieties about death, fate, control, contamination, loss, estrangement and others Weems, Russell, Neill, Berman, & Scott, 2016) . Psychotherapy researchers might seek to understand the effects of differing forms of existential anxiety on clients' specific symptom profiles, as well as client strengths or coping strategies that can mitigate these effects. For example, Kesebir (2014) found support for the hypothesis that humility represents a virtuous form of "quiet ego" (p. 610) that can buffer the impact of death anxiety. Steele (2020) noted the importance of attachment and reflective functioning research for the current pandemic and called for interventions that serve to "mentalize fear" (p. 97).

Strengths and virtues like humility, gratitude, forgiveness, mindfulness, hope and other widely studied constructs in positive psychology might be important predictors of client resilience and well-being in this COVID-19 context (Polizzi, Lynn, & Perry, 2020 ). Jankowski et al. (2020 argued to move psychotherapy research towards a dual focus on outcomes of symptom alleviation (the traditional focus of mental health care) and enhanced virtue and well-being. COVID-19's differing impacts appear to be resulting in a variety of trajectories for different clients, including increased symptomatology, increased well-being and a combination of the two. We recommend psychotherapy researchers include measures of both symptoms and well-being and seek to understand therapeutic processes and interventions that not only reduce symptoms but also facilitate the up-regulation of positive affect, virtue and well-being. This will also require research that attends to systemic, socio-economic and other contextual factors of privilege and oppression that can impact client well-being, as well as sensitivity to diverse definitions of well-being across cultural and SR traditions.

Relational disconnections around pandemic suffering also point to the need for psychotherapy research on complicated and traumatic forms of grief. Many people have suffered death in isolation with limited or no direct family contact, and this lack of physical connection is often compounded by complications to death rituals such as funerals and burial. These unique challenges to social connection in grieving processes may contribute to higher prevalence rates of prolonged or complicated grief disorders, and further research is needed on psychotherapies for those disorders. While communities of ritual (e.g., religious congregations) face new limitations for "hands on" involvement in the grief process, it will be useful to investigate the therapeutic role of technology-assisted community supports and other emerging forms of adapted ritual process to facilitate healing and meaning-making in the face of grief.

Social distancing guidelines and shelter-in-place advisories have affected families in extraordinary and unprecedented ways. One of the most salient challenges has been the pandemic's deleterious toll on the economy. Alarming rates of job loss and reduced wages have left families feeling the strain of economic hardship with uncertainty about when or whether they will recover, and those who were already financially disadvantaged seem especially at risk (Parker et al., 2020) . Previous research has documented the detrimental effects of financial stress on family relational processes, for example parental emotional distress and couple conflict leading to harsher parenting styles and more externalising behaviours in children (Neppl, Senia, & Donnellan, 2016) , as well as financial distress impacting marital quality through couple demand/withdraw patterns (Barton, Futris, & Nielsen, 2015) . Research on the impact of COVID-19's economic toll should examine how family relational processes are affected and subsequently contribute to individual and relational outcomes.

Families have also been affected by the loss of structured support found in extrafamilial systems, such as schools, childcare facilities or physical workplaces, leaving families with the responsibility to cover their functions alone. While families have likely struggled as a result of these losses, we also suspect many families have found creative solutions and urge researchers to examine indicators of resilience and coping alongside indicators of stress. Families have also spent considerably more time together, and researchers should investigate how extended periods of confinement have contributed to changes in family stability and functioning. While some families may be flourishing, seclusion from others and seldomly leaving home might also strain relationships or create safety concerns.

China has reported rising divorce rates following stay-at-home orders (Landsverk, 2020) , suggesting time together in isolation may exacerbate pre-existing issues or create new problems. Reports of domestic and sexual violence are also on the rise (Bradbury-Jones & Isham, 2020) . Family violence is known to increase during times when access to others (e.g., teachers, friends), who might notice signs of abuse or help victims access services, is limited (Boutilier, Jadidzadeh, Esina, Wells, & Kneebone, 2017) .

Families have been affected in countless other ways. Loved ones in nursing homes or hospitals have been unable to receive visitors.

Families have remained connected through video calls. Fertility clinics have closed, disrupting couples' attempts to conceive children.

As the pandemic unfolds, we urge clinicians and researchers to seek nuanced understanding of the ways families have been affected by various forms of loss, interruption of goals and ambiguity in decision-making. In addition to what families have experienced, investigating how families have responded to the changes imposed upon them will be important. Family stress and resilience scholars have found family coping largely depends on a family's perception of a stressful event and their awareness of and access to resources available to meet its demands (Price, Price, & McKenry, 2014) . Others suggest that flexibility in family roles and rules (as opposed to rigidity or chaos) and cohesion (as opposed to disengagement or enmeshment) is most conducive to successfully navigating periods of change (Olson, 2011) . While there may be fewer opportunities to directly intervene in the ways the pandemic has affected families, researchers are well positioned to examine the meanings families have created about their experiences, resources they have identified and accessed, and how relational functioning has been affected or contributes to individual and familial outcomes.

We have offered a perspective on some key directions for the research on counselling and psychotherapy in response to COVID-19.

These suggestions include increased attention to frontline healthcare workers, clinicians and the therapeutic process, the effects of information about COVID-19 and associated risks, discrimination and minority stress, engagement of spiritual and existential dynamics in psychotherapy and the impact on families. Clinicians may feel overwhelmed given the uncertainty and uncontrollable factors related to COVID-19, but research from previous crises or on adapting to stressful situations can inform clinical practice until research offers more pointed suggestions. While we urge the field to move forward with such endeavours, we recognise other areas of research may be warranted and exhort researchers to use their ingenuity and creativity to address the challenges created by the pandemic. 

Person of the therapist supervision: Reflections of a therapist and supervisor on empathic-identification and differentiation

Linking financial distress to marital quality: The intermediary roles of demand/withdraw and spousal gratitude expressions

The connection between professional sporting events, holidays, and domestic violence in Calgary

The pandemic paradox: The consequences of COVID-19 on domestic violence

FBI concerned about potential for hate crimes during coronavirus pandemic

Integrating clients' religion and spirituality within psychotherapy: A comprehensive meta-analysis

Racial discrimination and health outcomes among racial/ethnic minorities: A meta-analytic review

Could all those 'quarantinis' lead to drinking problems? The New York Times

Managing mental health challenges faced by healthcare workers during COVID-19 pandemic

Anti-Asian hate crimes up 21% in UK during coronavirus crisis. The Guardian

Functional fear predicts public health compliance in the COVID-19 pandemic

The Lives and Livelihoods of Many in the LGBTQ Community are at Risk Amidst COVID-19 Crisis

Are there interactional differences between telephone and face-to-face psychological therapy? A systematic review of comparative studies

Virtue, flourishing, and positive psychology in psychotherapy: An overview and research prospectus

A quiet ego quiets death anxiety: Humility as an existential anxiety buffer

They just see that you're Asian and you are horrible": How the pandemic is triggering racist attacks

Occurrence, prevention, and management of the psychological effects of merging virus outbreaks on health care workers: Rapid review and meta-analysis

The coronavirus may be driving up divorce rates in a Chinese city, official say. Business Insider

Countering COVID-19's mental health impact

Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence

Effects of economic hardship: Testing the family stress model over time

FACES IV and the circumplex model: Validation study

Religious and spiritual struggles and mental health: Implications for clinical practice

Stress and coping in the time of COVID-19: Pathways to resilience and recovery

Families coping with change: A conceptual overview

The effects of telepsychology format on empathic accuracy and the therapeutic alliance: An analogue counselling session

Relational spirituality in psychotherapy: Healing suffering and promoting growth

COVID-19, fear and the future: An attachment perspective

One in five Boston public school children may be virtual dropouts. The Boston Globe

Existential anxiety among adolescents exposed to disaster: Linkages among level of exposure, PTSD, and depression symptoms

Novel Coronavirus (2019-nCoV): Strategic preparedness and response plan

How nurses cope with patient death: A systematic review and qualitative meta-synthesis

Bell has published on the quantitative analysis of couple relational and mental health, and psychotherapy effectiveness in North America

Crabtree's clinical and research interests include the intersections of religion and spirituality, couple relationships, intercultural competence, systems of power and inequality, positive psychology and substance use

Hall concentrates his research and clinical work on LGBTQ issues, minority health, couple and family therapy, positive psychology and resilience

Sandage focuses his research and clinical practice in the areas of spirituality and psychotherapy, positive psychology, couple and family therapy, personality disorders, and intercultural competence and social justice