An Existential-Spiritual Journey During COVID-19

• A Place of Uncertainty
• Clinical Vignette
• Initial Phase: An Exploration of Death and Social Anxiety in the Context of COVID-19
• Middle Phase: A Shift in the Therapist’s Approach
• Working Though Phase: The Use of Creativity as a Spiritual Intervention
• Concluding Thoughts

A Place of Uncertainty

As we approach the second anniversary of the first detection of COVID-19, we are no longer in the acute stages of the pandemic. However, neither do we find ourselves squarely in a post-pandemic world, as new variants continue to evolve and spread rapidly, sparking fear and halting daily life. A heightened sense of self-doubt, vulnerability, and anxiety can occur in this “limbo-like” state, particularly for clients experiencing life-threatening medical conditions. Feeling threatened for prolonged periods may increase both the client’s and therapist’s need for certainty and diminish our ability to tolerate ambiguity. In the case of COVID-19, when safety and normalcy are in question, life’s uncertainties may be harder to endure.

Existential approaches are particularly well-suited for addressing concerns provoked by the COVID-19 pandemic such as encountering the fragility of life and the unpredictable nature of events, as well as uncertainty about when (or if) the pandemic will end. For Yalom, the aim of psychotherapy is to help clients fully experience and accept the existential anxieties associated with the “givens of existence,” including death, isolation, freedom, and meaninglessness. As a result of facing death, individuals may experience a sense of urgency to revise life priorities that can lead to improved meaning.

Existential therapists generally suggest that anxiety and existential guilt need to be experienced in an open and honest manner and, when directly encountered, can become a source of vitality, creativity, and purpose. Rollo May and Paul Tillich believed that courage and determination are fostered when anxiety, adversity, and life’s dilemmas are faced. In other words, when we accept our limitations, we also commit ourselves to living fully.

Victor Frankl’s recent series of posthumously published papers does this by shifting emphasis away from the question of “What can one expect from life?” to “What does life expect from us?” Thus, he suggests that it is life itself that asks questions about meaning. While we may feel challenged and forced to face discomfort when we ask ourselves what life expects from us, French philosopher Gabriel Marcel posited that such pain and suffering offer the only pathway to real insight and spiritual growth. Perhaps through these challenging questions that place uncertainty, obstacles, and suffering before us, we discover our meaning and purpose.

Clinical Vignette

The clinical vignette presented below highlights the challenges of how a therapist-client dyad worked through their mutual feelings of “not knowing” and uncertainty by processing their own existential anxieties and fears. A series of dreams of the client and therapist, as well as the use of creativity as a spiritual intervention, are described to demonstrate the complexity, practicality, and depth of the existential approach. In particular, the vignette highlights how dream interpretation can be used in enhancing problem-solving and conflict resolution, mastering trauma, exploring unknown possibilities and paths not chosen in life, wish fulfillment, compensation, communication with the therapist, and integration of self.

Initial Phase: An Exploration of Death and Social Anxiety in the Context of COVID-19

Steven is a 63-year-old man who presented for individual psychotherapy approximately six months after the resection of a non-malignant brain tumor. He experienced one generalized tonic-clonic seizure immediately after his tumor resection, which had a significant impact on his social and emotional functioning.

In terms of constitution, Steven had always been shy and sensitive. He had maintained a group of close friends since high school. Although he never married, he had had two long-term relationships since graduating from college. At the time of his surgery, he had been retired for two years from his career as a special education teacher and had reportedly been adjusting well to his life transition. Steven valued his level of independence, intellectual curiosity, and work ethic. His numerous interests included photography, hiking, reading history, and political activism. After the onset of his neurological condition, however, he became quite withdrawn and fearful about leaving his apartment. Although his seizures were well controlled with medication, the onset of his condition and the implied risks amplified his social anxieties and fear of death. Whenever he did leave his apartment, he felt self-conscious about his word-finding difficulty and occasional stutter, which exacerbated his fear of being ridiculed and shamed. After experiencing months of social isolation and increasing depression, he reached out for therapy at the encouragement of his physician and close friends. He hoped to regain self-confidence, be able to connect with old friends, and resume his recreational interests.

Steven’s comments about his own mortality were interspersed throughout the early sessions and were delivered in an intellectualized and affectively neutral manner. He recalled his experience of waking up from surgery and having a seizure in a vivid but emotionally detached manner, leaving me feeling highly anxious. I felt that he would have been frightened and overwhelmed if this had happened to him. These sessions felt more as if Steven was reporting about his life, rather than experiencing his life.

Given the news of the spread of COVID-19 in New York City during his third month of therapy, Steven agreed to continue sessions via telehealth. On top of the feelings of death and social anxiety and uncertainty secondary to his brain tumor and seizures, he felt the virus was exacerbating his lack of control over his life. Steven had a mindset that his medical condition and COVID were unsolvable problems leaving him trapped in his apartment with no escape.

In the first few telehealth sessions, there was a noticeable shift in Steven’s mood, focus, and communication style. Where previously he would speak at length about his negative interactions with the public in the local supermarket or in the elevator of his building in a detached fashion, his conversation in the context of the pandemic became more emotionally laden, his mood palpably more depressed, and his focus turned inward. While he had already worked through diminished control over his health and restrictions imposed by his physician and medications, COVID-19 surfaced additional fears of brain cancer and not being able to get help if he were to have another seizure.

The threat of COVID-19 increased the reality of his mortality due to his medical condition, and he could no longer speak about it indifferently. Instead, this emotional intensity filled the content of his thoughts and treatment sessions such that he grew more removed from the people and activities that had filled his time with meaning, purpose, and pleasure before his brain tumor. His increased level of avoidance, which had started after his surgery and was exacerbated by COVID-19, further impacted his sense of identity and agency in the world. For instance, Steven expressed that he was afraid of dying alone and nobody finding him. He did not have any religious affiliation but felt that he was a spiritual person when walking in nature or helping others who were vulnerable.

In the second month of treatment, Steven had reported a dream where he “was traversing over a deep canyon. As [he] cautiously walked across a wide rope with railings, it swayed back and forth. [He] saw a dark, shiny mountain across the cavern, but the rope was not attached to the mountain. [He] was unable to look down and felt paralyzed to take an additional step forward. [He] tried to scream out for help, but no words came out.” He woke up sweating and frightened. In session, Steven was asked to tell the dream in the present tense to promote a sense of presence and agency. When asked about the predominant feelings he had in the dream, Steven responded that he was overwhelmed with the anxiety of and fear of falling into the cavern that had no bottom. When asked how he would want the dream to end, he responded by wanting the rope to continue to the mountain so that he could feel safe with his feet firmly on the ground.

During the next few months of therapy, questions that had been previously effective with helping other clients with medical conditions and high levels of anxiety to gain a sense of meaning or agency (e.g., “What are some things that you can control now?” “What are your feelings of fear and anxiety trying to teach you?” and “What do you feel most passionate about in your life?”) were dismissed as unhelpful. Steven emphatically stated that he needed definitive answers to the questions that preoccupied his entire day, such as “Will my tumor grow back and become cancerous?” “If I exert myself through exercise or go to social events with my friends, will I get COVID or a seizure and die?” and “Is the government deliberately giving us misinformation regarding COVID-19?” I felt increasingly anxious and was unable to give a clear answer to any of these questions. As Steven’s therapist, my own experience of “not knowing” was overwhelming, since we were both experiencing our own feelings of anxiety, fear, and uncertainty about getting or spreading the virus. Steven tended to repetitively ask questions with no clear answers and would spend hours searching through social media sites for elucidation. Over time, he noted that the therapy was not helpful, even indicating that he felt more frustrated and withdrawn in both his sessions and his personal life.

Middle Phase: A Shift in the Therapist’s Approach

After consulting with several colleagues, I decided to focus on active listening, patience, tolerating silence, and providing space for Steven to find the words for his feelings. The decision to shift my therapeutic style with Steven was motivated in part by my experience of feeling alone in the room and that my words were not being heard; any interpretations or interventions offered were readily dismissed, as though batted away with a tennis racket. My reactions were further complicated by the difficulty of picking up nonverbal cues on the Zoom telecommunication platform. Ultimately, my countertransference reactions yielded a deeper appreciation for Steven’s emotional life, including his profound sense of isolation, powerlessness, and feeling invisible in the world. I was then able to provide Steven with titrated reflections of this loneliness and helplessness, contextualized within the uncertainty of the pandemic and his medical condition.

Shortly after I shared this particular self-disclosure and processed his reactions, I experienced a dream where “I was dragging a dead body of a man in a trash bag down a busy avenue in Manhattan. The bag was heavy, and it took a great effort to pull the bag toward Macy’s on 34th Street. I struggled to pull the bag toward the holiday window at Macy’s when the dream ended.” I understood the dream to be an indication that I was trying too hard and doing too much of the therapeutic work, and that Steven needed to take more responsibility and ownership of the course of the treatment. I also wondered about the meaning of the Macy’s holiday window scenes of families celebrating together, children playing, and religious scenes, and whether some creativity or spirituality needed to be part of the therapy in order to bring Steven to live more fully again.

This internal shift in my perspective led to a new phase in treatment where Steven was able to gradually mourn his loss of identity, direction, and purpose in life related to his medical condition and COVID-19. We began to explore his regrets in life. Steven was able to recall that he had always wanted to be a professional photographer but had not had the confidence to pursue this wish. He had always wanted to have children but felt that his career in special education partially fulfilled this desire. Shortly after, Steven recalled a dream where “[he] was in his parent’s country house in [his] room looking at a wall of his photographs from one of [his] high school classes. [He] noticed the subtleties of lightness and darkness in the scenes of Manhattan and started to experience a sense of pride and accomplishment. At that moment, [he] overheard [his] parents and other relatives laughing in another room, and [he] felt a sense of humiliation and shame that they were making fun of [his] photographs.” He awoke feeling a sense of hope about his creative abilities and a sense that he now had the time to act on it. He also felt that he did not trust his desires when he was younger and was more concerned about what others would say about his artistic ability. When asked of his associations to the dream, Steven mentioned that the night before he had watched a film of someone who spent years walking every street in the five boroughs of New York. Steven regretfully said that he wished he had the courage and confidence to pursue his deeply-buried artistic dreams.

Working Though Phase: The Use of Creativity as a Spiritual Intervention

After a period of medical improvement, including being seizure-free, Steven started going out of his apartment a few days a week to take black and white photographs in Central Park. During the early morning hours, he experienced a sense of awe, wonder, and adventure in not knowing where his walks would lead in the park. He took black and white pictures of statues, lights filtering through leaves on the trees, animals resting in the zoo, and a formation of geese flying over a pond. Steven experienced a greater sense of freedom, calm, and centeredness during these occasions. His rediscovered artistic passions, which resulted in increased flexibility and confidence in taking risks in other aspects of his life, including contacting friends and colleagues with whom he had lost contact. These photographs activated something on a deeper level in Steven and enabled sharing these photographs with his older friends. He initiated contact with his former school and volunteered to teach photography in a small group setting, which provided a sense of purpose and direction in life.

As Steven’s level of anxiety and medical symptoms improved, he was able to shift his focus from internal preoccupations with not knowing what his future would be like to existential concepts of meaning, values, and priorities. He thought more about his future, making peace with external things that he did not have control over. Steven shifted his position from the passenger seat to taking a more active approach in life. He became curious about how he wanted to lead his life and pursue his social and recreational interests. I facilitated this process by open-ended questions, such as “What has sustained you in dealing with your medical issues?” “Where do you think you found your strength?” and “If you were to imagine your life one year from now, looking back on how you dealt with your medical recovery, what would you think about how you handled things?” In addition, I asked, “If you had not had your neurological condition, would you be dealing with the pandemic any differently (and vice versa)?”

Steven realized that when he began treatment he had been feeling sorry for himself and angry at the unfairness and injustice of having a medical condition after being a good person who devoted his life to helping others. He realized that he was fearful of taking risks and failing, and that he had more to give to others despite his limitations. Steven acknowledged the importance of his friendships and of continuing to develop his personal values and traits. He gradually came to realize his own power to choose how he wanted to view and respond to life’s major challenges. Furthermore, he started to become aware of ways in which his medical condition had made him stronger, including being able to face his mortality and tolerating not knowing and uncertainty. He was eventually able to acknowledge that his courage, determination, and creativity enabled him to cope with his multiple challenges and that he had more to live for.

Concluding Thoughts

Existential approaches are uniquely suited to address prominent themes in the COVID-19 pandemic, including anxiety surrounding death, uncertainty, isolation, and vulnerability. Existential therapy provides an important opportunity for clients and their therapists together to face these challenges and discover meaning throughout. Through the process, they are able to live life with greater intention, purpose, self-reflection, and presence, to accept and learn from feelings of not knowing, uncertainty, and anxiety, and to value the benefits of choosing one’s attitude toward adversity.

This case vignette highlights the benefits for both the client and therapist in experiencing, accepting, and learning from feelings of uncertainty. Asking open-ended questions about Steven’s dreams, values, attitudes, and meaning in life enabled him to be more curious and flexible. Incorporating creativity as a spiritual intervention provided an opportunity for a heightened degree of engagement, self-reflection, intensity, hope, and passion. In a parallel manner, my therapeutic shift to slowing down the pace and focusing on the process, tolerating moments of silence, utilizing countertransference reactions, and reflecting on his and my own dreams enabled me to let go of the need to appear as an expert with all of the answers and be more of a “fellow traveler.”

There are moments when clients need their therapists to feel the depths of their powerlessness, loss, vulnerability, and despair in order to find and describe their feelings and to feel understood and emotionally held. There are healing moments when the most important gift that we bring to another person is the silence within us, the kind that is a source of peace, acceptance, and allows the transitional space to be.

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