I typically see people for psychotherapy after they’ve broken through denial but before they reach a state of true acceptance. Often, they come to my office wanting something to change but wanting to change nothing in themselves.
Once we get to the radical acceptance phase, they’re able to stop vacillating between one strong emotion and its opposite and take a realistic look at their situations, the obstacles to their recovery, and also at their strengths, as well as any growth opportunities the process of recovery may provide.
This step I call the Assess step. Here, several important questions come up:
- How did I get here?
- Where is here?
- What are my options now?
- How can I get back to some kind of normal life?
These are the questions we are asking in this global crisis, both as individuals and as a species.
Though I’d been slouching toward the Assess step for several weeks, I didn’t actually arrive there until I’d absorbed the impact of my brother’s illness. Then, I understood, on more than a “numbers game” level, that it was not only possible, but also probable, that people close to me might not live to see the other side of the pandemic, and that I, too, might die before it ended.
Unconsciously, I followed Abraham Maslow’s Hierarchy of Needs through this step.
Maslow’s theory is that we try to satisfy our basic physiological needs first, such as for food, shelter, and warmth. Then we move up the Hierarchy, seeking to satisfy each of the higher-level categories in approximately the order illustrated below.
Safety. As I’d learned in an Intro to Psych class fifty years ago, after we meet our basic physiological needs, we seek safety.
Early in the pandemic, data on who gets sick and who dies was scarce, but as the disease plowed through Asia, Europe, and across North America, the numbers began rolling in, and epidemiologists started to crunch them.
By mid-March, it was apparent that being 65 or older substantially increased the risk of severe disease and death. I’m 69. Check. Underlying health conditions emerged as an important factor, too, especially heart disease, diabetes, chronic pulmonary issues, obesity, and hypertension. Diabetes, asthma, hypertension. Check, check, check. And, men appeared to die of COVID-19 more frequently than did women. Check.
I couldn’t control any of these risk factors. What could I?
Incessant Internet searches deep into several nights revealed that there was a correlation between people who took a commonly prescribed class of hypertension medications and greater mortality from COVID-19. I was on one of those medications.
I spent the next seven days relentlessly experimenting with leftover medications from earlier hypertension-management regimens, seeking a different way to balance my blood pressure. I checked my blood pressure in the morning, several times during the day, and at night. In the end, I relented. I could not manage my hypertension without that medication. Check.
Avoiding exposure, then, was my only defense, and this became my next focus.
On my second post-Detect trip to a grocery store and a pharmacy, I saw how these locations were perfect disease vectors. I could almost see the virus particles emanating from cashiers, baggers, other customers, and lying in wait on the thousands of potentially contaminated surfaces. I arranged to have all my groceries and prescriptions delivered, from that day forward. Check.
Then there were masks. In all the stories I’d read in the South China Morning Post, everyone pictured, even government officials, was wearing a face mask, which they clearly believed offered some protection. Although the CDC continued to instruct us not to wear masks, how could it hurt? By then, there were none left to buy, so, after watching about a dozen instructional YouTube videos, I made two crude masks from a cut-up pillowcase, rubber bands, staples, and paperclips. Check, check.
After running into a downstairs neighbor at the doorway to our building, I became preoccupied with avoiding contact with the other residents of my building. Any of them might be infected. How could I know? So I listened at doorways for coughs, listened in hallways for sounds of activity, and left my apartment only when the coast was clear. Check. Next, there was the basement laundry room. In the 12 years I’d lived in the building, I’d never run into anyone there. Still…. When I ran out of clean underwear, my girlfriend offered to let me do laundry at her house, and though I felt like a college kid bringing his dirty clothes home to mom, I accepted her offer. Check.
Finally, there were friends and family. No way to know if any of them were safe, either, so I canceled a trip to New York State to visit one of my brothers and my mother, canceled plans to meet friends for coffee, and declined an invitation to spend time with a friend in a nearby park when he mentioned “waiting for this thing to blow over.” Blow over? My girlfriend and I decided to limit our exposure only to each other and “meet” anyone else on screen. Check, check, check.
Financial. Moving up Maslow’s hierarchy, I assessed my financial security.
Before the pandemic, I’d set aside enough investments to get within a year of the enviable status my girlfriend enjoyed after she retired from her law practice. We’d already started to talk about trips we’d take in the U.S. and abroad: a tour of the Southwest, a road trip through the South, visits to the legendary national parks, a return visit to Paris, a sojourn to the Promised Land, where her youngest son and his family lived.
But much of my retirement stash had vanished in the initial coronavirus crash and I lost more through panic selling in my “hair on fire” phase. When would the market hit bottom and how low would it go? Nobody knew. Retiring was now a distant dream.
Connection. Next on the hierarchy of needs came connections, or as Maslow put it, “social belonging.”
As an introvert, I can handle a few days alone and feel no lack of human contact. But that doesn’t mean I prefer to be alone. With my girlfriend’s and my decision to create a bubble in which we were the only occupants came a vague feeling of disconnection. I have always enjoyed the proximity of fellow human beings: dining out, watching a play or film in a darkened theater, or hanging out in a café, as well as my closer connection with clients, friends, and family. Would “seeing” people only through video conferencing be enough? Another unknown.
Esteem needs. It would take months for me to ascend further up Maslow’s hierarchy into what he calls “esteem needs,” such as resuming creative work and reconnecting with my spiritual side. What’s the point, I thought, in a pandemic?
These were some of the questions I asked during the Assess step.
As the crisis evolved, our assessment processes evolved along with it, each in our own way and at our own pace, all of us advancing through our personal hierarchy of needs.
Those who didn’t feel physically threatened by the virus focused on finances. Those who didn’t feel financially threatened focused on relationships. Those who didn’t focus on relationships longed for what they missed from the pre-pandemic world, now the eerily distant past of only weeks before.
Confinement, stress, and fear have brought out into the open the strengths and difficulties in relationships. Bonds between couples and families strained and sometimes cracked. Some grew stronger than they’d been, overcoming rifts that, in more normal times, would have created permanent fractures. Some were ripped apart. I’ve received frantic texts from clients who, kicked out of their homes after tempers flared, asked for advice on whether to sleep on a friend’s couch or in their cars.
Municipalities, states, and nations grudgingly accepted that their hold on the world they’d known was tenuous, as they weighed and measured the costs of battling this “invisible enemy” in a delicate balance between money and lives.
At one extreme was Hong Kong where, the previous summer, I had wandered through the bustling streets, dipping into shops and restaurants, absorbing the sights and sounds and smells of an intense tableau. I marveled at the absence of shouting or car horns, and appreciated the quiet, patient people who queued up at street corners, waiting for the lights to change. Though only a stone’s throw from mainland China, the Hong Kong government and its citizens swiftly stemmed the spread of infection and kept it contained.
At the opposite extreme was my country, the United States of America, whose sluggish, uneven response led to unparalleled social and economic chaos, with infections, deaths, and economic turmoil unmatched by any other nation. By early May, the infected and the dead in my state alone, Massachusetts, with its population of 6.9 million, had already exceeded those who had sickened or died in all of China’s 1.4 billion.
Regardless of their efficacy, the movement through phases of assessment for each of us individually, as well as for each of our respective nations, was much the same.
Our first responses were mostly intuitive and reactive. We groped uncertainly through the darkness of our ignorance, seeking some understanding of what had befallen us, grasping at whatever trends in the contagion and in its effects on our lives we could suss out, matching the problems of illness, death, and economic chaos with fumbling efforts not only to contain the virus, but also to prevent our economies from self-destructing.
We saw this matching of problems and resources in the national, state, and local governments’ efforts to shut down their respective activities. Restrictions on how people worked, shopped, and sought entertainment were gradually, tentatively applied, followed by stronger limitations on how many of us could gather in one place, how far we should stand or sit from one another, whether we should or should not cover our faces, and even which side of the street we should walk down to minimize contact with our neighbors.
We saw the pharmaceutical industry matching the machinations of the virus to the vast pharmacopoeia that had been developed and approved to combat diverse diseases, while at the same time they began a worldwide race to be the first to find the Holy Grail, an effective vaccine or cure.
We saw a succession of financial stimulus packages quickly drawn up and implemented, while at the same time demand on food banks overwhelmed their ability to respond and state unemployment insurance funds ran out of money.
We saw investors weighing the relative value of stocks, bonds, and commodities second by second, matching each piece of news with their best guesses at its potential effect on the collapsing economic engines of the human world.
We saw families creating safety bubbles amidst all this turmoil, and then recreating them as the winds of change in the outside world caused them to burst.
We witnessed these rolling assessments in every aspect of our lives, in every corner of the globe.
When I look back at these efforts to adapt to an ever-changing landscape of disease and disorder, I am reminded of a remark a co-worker made, long ago, about our work as software technical writers, documenting the functions of computer programs while they underwent continual revision. “It’s like trying to nail Jello to a wall,” he said.
Technique: The Circles of Problems and Resources
Even when we’re down for the count, however, most of us have more ability to deal with the forces that have unbalanced us than we realize, even when those forces are outside our direct control.
To begin recovery, we need to draw our attention to the resources we already have, or to resources we may not have imagined beforehand but which our new path now reveals.
With my clients, I often use a simple but effective tool I call the Circles of Problems and Resources, or CPR, to help them get their bearings and ready themselves for the journey back to balance.
The CPR can also serve as a tool for visualizing how we, as a people, can begin the process of resuscitating our pandemic-stricken world.
Here’s how to create your own CPR:
Start by drawing a doughnut shape that fills most of the middle of a single sheet of paper. Inside the innermost circle, list the problems you’re experiencing. In the outer circle, write the internal resources that might help with these problems. Then, in the area outside the doughnut, list the external resources that also could be helpful.
Resources are internal if you can do them without having to engage the external world. Resources are external if doing them requires interacting directly with the outside world. For instance, in the example below, exercise at home would be an internal resource, but exercising at the gym requires an external resource.
Here’s a blank template and beside it an example of problems and resources from a period during which I was dealing with work burnout:
After you complete your lists of problems and resources, one by one, draw lines to connect each of the problems in the inner circle with the internal resources in the outer circle that might help to resolve them. Then, do the same thing with the problems in the inner circle and the external resources in the area outside the doughnut.
Here’s an example of how the problem of exhaustion can be linked to potentially helpful internal and external resources. Beside it is the completed CPR.
Note that when you connect problems with resources, the same resource might help with multiple problems. In this example, exercise helps with both exhaustion and depression. Also, multiple resources can help with the same problem. In this example, friends, family, going to the gym, and participating in groups can all be helpful with mitigating isolation.
In the first stages of the pandemic, stay-at-home orders made some of our go-to resources unavailable, or available only in an altered form. When this happens, we need to find equivalents and alternatives. For example, a teenager who enjoys singing in a chorus can look for an online collaborative singing group. Socially-distanced hikes can easily substitute for ordinary hikes. In-person personal training or workouts translate fairly well to Zoom sessions. In my field, telemedicine has become the replacement for in-person meetings.
The CPR is as helpful in a global crisis as it is in a personal one. Since the stay-at-home orders began, many of my former clients returned to therapy with heightened problems, and I was soon seeing nearly twice as many as I had before the pandemic. I saw myself moving toward burnout again. My main symptoms were anxiety, insomnia, exhaustion, and isolation.
Here’s a modified version of my CPR, adapted to the current socially-distant environment:
I’ve always used the CPR as a personal self-help tool, but I can see that it could be applied at the community and global levels, too, to inventory problems and resources and the links between them. A greatly simplified version might look like the illustrations below.
The left-most illustration shows only problems and resources. In the right-most version, I’ve started to match the problems with individual and external resources that could help to resolve them.
In this global version of the CPR, the inner circle still contains the problems of the disease itself and three its societal effects.
The doughnut contains potentially beneficial qualities and activities that we, as individuals, can apply to these problems. The area outside the doughnut lists some of the regional, national, or global resources that could help us recover our balance as a species.
A practical application of this tool to the pandemic would, of course, be much more detailed and much more complex.
Were we to assess the problems of the pandemic in a coordinated way, we would lay out all the problems we need to solve and all the resources that could help to solve them, and then connect the dots, thereby creating a map to guide us out of chaos and back to a new – and, I hope, better – world.
To be continued…
Copyright 2020, David J. Bookbinder