Audio Update Archives

Heather MacIntosh ‘Big T’ vs. ‘little t’ trauma

In your blog post you make the distinction between ‘Big T’ and ‘little t’. What is that distinction?

It’s a very generic term, it’s a big of a colloquialism, but the idea is that there are things that happen to us in life that are difficult, and can at the time feel traumatic. But they don’t knock us off our socks. So a ‘little t’ trauma would be something like a major life event – the loss of a partner, a big breakup.

But a ‘Big T’ trauma is something that really knocks your socks off. It’s something that causes you to have to stop in your tracks, regroup, and kind of figure out the meaning of life again. Those traumas are things like sexual abuse or sexual violence, domestic violence in the home. Things where your life is put at threat, or you’re witnessing someone else’s life at threat. Where there’s a lot of terror and helplessness.

And so the impacts of those different events are very different long term. And that’s not to say that what is a ‘Big T’ trauma to one person might not be a ‘little t’ trauma to someone else. So much is about where we come from, our own experiences growing up and how secure we feel in ourselves, and the age and stage we are at when those things happen.

Would you say that in the current situation with the added stress, the added fear, and the added anxiety, that more often what would have been a small t trauma can turn into a big t trauma?

Part of what is unique about this situation is the sense of helplessness that people have about being unable to do much about it. So there’s a global thing that’s happening. This pandemic has a very particular trajectory. On the one hand we’re being told stay home, that’s the thing you can do to help. On the other hand we’re being told that it could get out of control and everyone’s health could be at risk.

For people who are in first responder situations it’s very difficult at some level – I’m not an epidemiologist so I can’t really speak to this – there is a concern that infection rates among first responders are really high. So for the people who feel like there’s something they’re actively doing out in the world to mitigate by providing various services, those people’s lives are at risk by doing the thing they do. So that fits into one category.

Then there are the people who are staying at home and providing (like myself) mental health services. We’re watching people on the front lines as we provide services, and the CPA has come up with a list of psychologists who are willing to do some pro-bono services, I’m also on that list. We’re a little bit feeling helpless about how to be most of service. That can really feed into a sense of the heightening of the fight-flight-and-freeze response.

Some of us feel – and again this is very much about where we come from in terms of our own lives and our own traumas – being in our homes can feel very traumatizing, so something that might be a stressor like worrying about a family member being sick, having a parent in a retirement home.

In the past you might have gone to the gym, gone for a run, gone out with a friend. You might have had a number of strategies you would use that would help you manage that fight-flight-freeze response. Now we’re being asked to stay at home and so the fight-flight-freeze has nowhere to go.

Thankfully there are a lot of really amazing people putting meditations online, putting yogas online, putting various resources including psychotherapy into online spaces. And I would really encourage people to use those resources, because being able to connect with someone outside of your family unit, to be able to be as honest as you need to be about how distressed you are, may make a real difference in how people come out of this.

Dr. Karen Cohen on telehealth advocacy

What is on the docket for the CPA in terms of advocacy for psychologists doing tele-psychology?

Advocacy for access to funded psychological services has been on the docket for us for some time. I think there are some exciting things happening now. The Canadian Alliance for Mental Illness and Mental Health (CAMIMH), for example, is putting together a policy position calling for parity – so, requiring our governments and funders to provide coverage equivalently for mental and physical disorders.

HEAL, which is organizations for Health Action, all the national health care organizations, also has access to mental health services as one of it’s advocacy priorities. And the Mental Health Commission of Canada (MHCC) has put together a network on which CPA sits, looking at access to psychotherapies for Canadians. So that work will continue.

In the current situation, we’ve been in touch with the Canadian Life and Health Insurance Association (CLHIA) and we’ve been calling on them to reach out to all their members, who are all the individual insurers, to cover services delivered virtually by psychologists. Every plan differs and that’s one of the challenges when it comes to doing advocacy when it comes to access, particularly in the private sector. There’s not one funder and there’s not one plan and there’s not one plan sponsor. They all have oversight individually over what those plans look like, so you can imagine how many conversations have to be had to make the change we’re looking for.

This is why it’s helpful to have an organization like CLHIA, because they have a conduit to their insurance members. The other thing we’ve been asking them is that some policies have a requirement for a physician referral. So to access a psychologist, the plan will cover it IF you’re referred by a physician. We’ve been calling on them for some time to waive this requirement, and especially now.

Our health providers – family doctors, nurses, nurse practitioners – are working hard to address the needs of patients and particularly the needs of patients who might have concerns about COVID. Having them make a referral to a psychologist who is someone you could otherwise see without the referral, doesn’t make a lot of sense. So we’re working hard to try to advocate for that as well.

Dr. Karen Cohen on the Psychology Practice Fact Sheet & Tele-Health

On the fact sheet you wrote, Psychological Practice and the Coronavirus, you mention growing evidence that psychological services can be delivered effectively through tele-health. What is that evidence?

I would encourage folks who want to learn more about the delivery of psychological services through electronic media to read some of the work that’s being done now by psychologist members – Dr. Heather Hadjistavropoulous, Dr. Stephane Bouchard, Dr. Peter Cornish. There really is mounting evidence that internet-delivered CBT is effective in the treatment of depression and anxiety.

I think there are things you need to know if you’re going to adapt your service to deliver it virtually. We have some excellent materials on the COVID page of our website and resources for folks who want to inform themselves, and some of the things they need to know when delivering services in that way.

Assuming you’re a practitioner who has a private and secure platform to do tele-psychology, what are a few of the things they need to know?

Obviously, you need to talk to your clients about their comfort using that technology, you need to be sure that whatever mechanism you choose is safe and secure. You need to know you’re always talking to your client, you need to use passwords to confirm their identity when that’s necessary.

BMS, who’s the broker of our professional liability insurance program, and our preferred legal provider Gowlings, have a series of fact sheets, also on our COVID website, that talk about things you need to be aware of when you deliver tele-psychology. You want to be aware whether your client’s insurance is going to pay for a session delivered by tele-psychology. Or you can have your client find that out before you begin, don’t assume it will necessarily be the case.

It’s always a good idea to put on a receipt the type of service that was delivered and in what format. Inform yourself on the things that impact the delivery of psychological service differently when you’re delivering it virtually.

I saw a few health insurers come out and say they’ll be covering tele-psychology in what appears to be a blanket way. Sun Life I think was one. If you saw your health insurance provider come out and say that, can you assume that you’re covered and you’re good to go with virtual therapy sessions?

Not necessarily. I think the issue is that although the insurer may decide that given COVID or for any other reason they’re going to cover tele-psychology, it’s important to understand that everyone’s plan isn’t necessarily the same. If two people had different policies, which they would if they had two different employers, they would still need to confirm that that particular policy will cover it.

You’ve said there are skills and competencies unique to tele-psychology. What are some of those?

It’s probably best for our membership to consult those who are more expert than I. Dr. Christine Korol, for example, has some resources on her website that would be very useful. In broad strokes, it’s about your comfort with technology, that you go seek out training from folks who have made a practice of delivering psychological services virtually so you know what those are and are aware of any differences that method of service delivery can present.

You’ll want to know how to prepare your clients for working in this way, make sure they’re comfortable with it and you understand their comfort with it. The important thing to keep in mind is that all other professional standards still apply. Everything you would need to do in terms of competencies and skills and informed consent and continuity of care when you’re delivering care face to face would still apply when you’re delivering care virtually.

I’ve been talking to Dr. Korol, and she suggested getting a white noise machine to put outside your home office so as not to be interrupted and ensure privacy.

Those are things that would apply in any setting, of course. In a busy clinic you might need a white noise machine outside any room to ensure privacy as well. So some of the things are very transferrable, and some are more particular to that kind of service delivery.

I think it’s worth underscoring that there are some populations for whom telepsychology might work even better. If you’re in a rural or remote location, or up north in a province where there aren’t a lot of psychologists in that area, being able to talk to one virtually could be wonderful. If you have any kind of mobility issues, or you’re a senior, it may be easier for you to talk to someone from your own home rather than travelling a physical distance to meet them.

One of the things we’ve been talking about as health professional organizations, and we’ve been meeting regularly and sharing resources around COVID, is “will COVID change the way we deliver health care?” Psychology is one of those professions that lends itself a little more easily to tele-health than other professions. You know dentists, for example, would have a lot of trouble doing their work virtually.

Maybe we’re ramping up a little quicker now with COVID, and those practitioners who maybe weren’t using tele-psychology much are now doing more so now. But are these changes that are going to be permanent in the fabric of health care and tele-health care?

It may be a learning curve right now in terms of delivering and receiving these services, but in the future it might become a whole new business model – do you think that’s likely?

I think so! I think once people become familiar, and see how these services can be best delivered within the context of their scope of practice, I do think we’ll see it more and more. I know that as an association we’ve been working very hard with a practice management platform to bring an offering to our members. Hopefully we’re just on the verge of being able to announce that. It’s one that really has the psychologist-practitioner at the centre, and features a whole suite of services to help you manage your practice.

I think that one of the things individual practitioners run up against is that when you’re a salaried practitioner at a hospital or a school you have an institution to rely on who does some of that diligence around providing a secure and private platform. But when you’re in private practice and you don’t have that institutional resource, there’s more pressure on you to make the best choice. That it’s a practice management offering that meets your needs, that’s secure, that’s private.

So, as an association we hope to be able to do some of that diligence for our members and we hope to be able to announce this offering very shortly.

Alright, now I want to talk about remote dentistry.

Dr Heather MacIntosh what worries you most

You said your blog post was inspired by news stories warning of a rise in domestic violence while people were being encouraged to stay home, and you said this worried you a great deal. What worries you most?

One of the things that happens a lot – if you’re a couples therapist this will resonate with you – is that couples will come in well down the road in their distress. So they don’t often come in at the point where we’re doing preventative health, they come in at the point where they’re very distressed. And one of the things that a couple will often say at the beginning of a session will be something like “I held onto this to discuss it here, because I was afraid that it would explode if I tried to talk about it at home”.

Often couples who are in a lot of distress are dealing with what we call ‘emotional disregulation’, so difficulty handling the emotions they’re having about the distress that they have with their partner. Because of course we know that while partners can be the people who help us feel better, when things aren’t going well they can also be the person who makes us feel worse. So one of my real concerns is that putting couples into isolation together, adding children without childcare, animals, financial difficulties, we’re raising the level of stress and reducing the level of support.

Depending on the context for this couple or family, this could be something that brings them together, and helps them build a sense of closeness and an identity as a family unit. But it can also, in the context where there might be a history of trauma, or a history of distress in this couple relationship, it can also be the thing that pushes them over the edge in terms of their ability to cope with the distress they’re having.

Sometimes even just going for a walk can help us blow off a little steam, for lack of a better word. And what we’re being told is that unless it’s that once-a-week trip for groceries, we shouldn’t be leaving the house.

So my concern was that for many – and I’ll speak for myself – I work ongoingly with couples who have a history of trauma, and we had sessions the week before the world basically locked down, and that was that. So even couples who have been in therapy for various reasons some of them have not been able to continue therapy virtually. Now all of a sudden there they are at home alone, in their distress, with more financial pressures, more things to worry about, and none of the supports they had before.

I imagine that even for those who are able to do long-distance therapy, it’s a difficult thing for them because they’re doing it from their home, where their partner lives.

Yes, that’s part of it. But there’s a debate – should people learn how to do individual therapy first, or should they learn how to do couples therapy and group therapy first? There are people who say that if you learn how to do individual therapy first, couples therapy is going to be overwhelming. Others say learn how to do couples therapy first because then individual therapy will be less stressful.

The reality is, when you’re doing individual therapy, even on Zoom or one of these platforms, the relationship that you’re working on is the relationship between you and your therapist. And if you have a conflict with that person, part of the therapy is trying to figure out how to work that through. It’s part of what makes the therapy helpful, having what we call a ‘rupture’ or something that doesn’t go so well, and figuring it out.

But that person, the therapist, is not your wife. It’s not your child. It’s not, for lack of a better term, the “real attachment relationship” with the person you’re connected with. And you also get to go home after your therapy session. Imagine then, when we put partners together in therapy, especially when there’s a history of trauma, either between the couple or in their past, the emotional intensity of those sessions goes way way up.

Part of what we’re doing is helping the couple manage that emotional intensity but still trying to resolve the difficulties that brought them in in the first place. So it’s a more complicated juggling of emotional arousal. Doing that over the internet where the two people are together – and maybe they’ve got kids around and the dogs are barking – is going to be a higher octane experience than going off into the bedroom, shutting the door, and talking to your individual therapist.

I’m also a little worried about how we’re going to manage that piece of things. Because while we want to continue to offer support, it’s really essential that we don’t make things worse.

Karen Cohen pro-bono initiative

A child and youth psychologist wants to help out – what can they do?

Because the scope of the service is to provide help to adult health care workers, it’s important that whoever signs on has that competency. Obviously psychologists who work with families and kids have important contributions to make. But given the initiative is aimed at adults, it will be important that anyone who signs on has the competency to work with that age group.

We’re also getting some questions from Quebec – a lot of psychologists there want to sign on. Is there a different process for them?

Everything’s been translated – the materials, the lists, you’ll notice that on the listings [of psychologists who have signed on to do pro-bono work with front line health care providers] some key things. The psychologist’s name, their coordinates, where they’re licensed, and what languages they speak. So absolutely! Un grand bienvenue à nos collègues à Québec – we welcome your participation, and that would be a huge contribution!

Christine Korol quick chat coping if you are already dealing with anxiety, OCD, etc.

Let’s talk about coping with this current situation if you are already dealing with something like anxiety, OCD, or another issue of that nature.

It’s hard, and you’ll have to do this on an individual basis with your clients. I have a lot of people who are making terrific progress, whether they have social anxiety or a bit of agoraphobia, and they’re getting out of the house more. They’re back in the house now and a lot of them are telling me “you know, I actually know how to be okay in here”. So they’re okay but they’re worried about how to manage when this is all over. I remind them the learning curve will be shorter, they know what to do, that they can continue to develop connections and find meaningful things to do while they’re in isolation. That’s been tough.

For OCD cases, the patients that I’m working with that are afraid of germs or that wash their hands too much, we’ve been working a lot on sticking to guidelines. I’ve been emphasizing too that this is not like regular germs or viruses, this is not something we have an immunity to, and we have a very high risk of complications for other people. So we have to flatten the curve right now to help health care workers manage with the influx and protect the people that we care about.

So this is a very unusual situation and hopefully in a year, or however long it takes, we get through this dark tunnel and come out the other side. Another issue is that uncertainty, with anxious people, that’s something we’re working on too. Once we get through that tunnel public health will direct us to what is safe again. Many of my patients are hand washers, and we talk about how they’re washing their hands much more than surgeons are. So we try to keep it within those bounds recommended by public health.

For some of them, they’re still worried about contamination from things that aren’t high-risk for spreading COVID-19, which might be things in their house or they’re afraid of touching the bottle of bleach or other things. So we can still work on that. There are some interesting things you can do with tele-therapy. I’ve actually been using tele-therapy to kind of do home visits with OCD patients for some time now. That hasn’t changed, so I can still do things like exposure therapy. They can show me if they’re afraid of their laundry room, or afraid of cleaning their toilet, we can still work on that kind of stuff remotely.

Christine Korol quick chat the fear of losing someone

I know a lot of us are feeling this right now, the fear of losing someone close to us. Yesterday my neighbour stopped by, and we stayed far apart in the driveway and had glasses of wine (each from our own house) while she told us her grandmother had just died in Germany. And we couldn’t hug her, and we couldn’t comfort her the way we normally would. It all had to be done from a distance.

It’s just so brutal, what’s going to happen. I’ve heard some predictions that everyone’s going to know at least one person who died from COVID-19. And that’s if it goes well – we’re all going to know at least one person, if each person knows about 300 people. And it’s not that big a stretch to imagine that.

So it’s no funerals, no touching, no comforting, no hugging. It’s going to be very hard to help people process all of this. Therapists need to make sure that they take care of themselves, and that they have people to talk to and process this information. It’s a good time for therapists to brush up on grief therapy, and to be comfortable having those conversations with people about the loss of their loved one. There’s a lot of education about the ‘trajectory of loss’, about how long the raw pain lasts, what causes a complicated grief, and how to help people if there is a complicated grief.

There is going to be a lot of loss and trauma coming up. How we can help people with that is really knowing how to talk about loss and grief. And then for some people if they’re at higher risk, and they think they might lose that person, if they’re worried about an elderly relative for example, encouraging them to talk to that relative now. To make the most of the time we have here.

What can help reduce anxiety around death and loss is to actually talk about a death plan. Find out what your family members want – and we should actually be doing this anyway – but it does reduce anxiety if we can be open with them and talk to people about death. For the people who have been coming to me worried about grandparents or people with immune disorders or pre-existing conditions, I’ve been encouraging them to openly talk about death with their parents or grandparents and say “are you worried about this, is there anything I can do?”

It’s often a relief for people when you can talk about death. I think that would be an important part of public education as well, that we really don’t talk about death. You know, 100 years ago people used to wear black for a year to signify they were in mourning, and the community would rally around them. People had wakes in their homes, and would die at home, and so there was a greater comfort with death. There was still the pain of death, and people understood that people in mourning needed support, but we really need to understand that death can happen at any time and so we need to have those conversations with people.

It’s not morbid, it’s the reality of our situation. Maybe we can have those conversations and not leave our at-risk family members worrying and pretending that everything is okay. They can have these conversations and that will reduce their anxiety.

Christine Korol quick chat anger toward people who are not taking COVID seriously

You’ve spoken about people who get angry when they see others not taking COVID seriously. Some of those angry people have been health care workers, but what are you seeing from the general public?

What I’ve been telling people is that everybody copes with stress differently. And I think there haven’t been a lot of clear messages up to this point. Things are getting clearer now, but you see different restrictions in different communities, and in different provinces and different countries.

There’s a lot of information coming at us, and the communication on an individual level of what you should be doing in your community is actually kind of hard to find. I try to keep up to date with it myself and I find it rather difficult at times so hopefully that becomes clearer.

Public health has to be the one to police people. You can’t be the COVID police. You also don’t know how people are coping with this, and some people cope by not turning on the news. And that’s something that we tell people to do all the time. If you’re feeling anxious stop watching the news 24/7. But in this case you do have to watch some news because it is changing so quickly every day, so you know what you’re allowed to do and not do.

So when you get angry with friends or family members or you see someone you don’t know on the street or gathering in groups, it’s important to know we’re autonomous people. We have to make our own decisions. We’re all processing this difficult decision differently. And some people are dealing with their anxiety by going outside and not reading the news. So you have to be patient with people, and understand that this is a difficult situation, it’s unprecedented, but it really takes a larger voice than your own to change somebody’s mind about what’s safe and what’s not safe.

Plus you know I run an anxiety centre so a lot of my patients tend to be kind of nervous, and their families kind of tune them out. So I bring that up with my anxious patients, that it’s almost like people look at us like we’re Chicken Little when we’re anxious. That we say “don’t do this” and “don’t do that” and now it’s “here we go again with COVID-19” and they’re not taking it seriously. And you might not be the person to change their minds.

So anger with these people is unproductive. But I’m wondering how I can convince my 70-year-old mom, who lives in Winnipeg, that she’s not going to be able to keep her church basement bookstore open.

Yeah, you won’t be able to do it, probably. I’ve never been able to change any of my relatives’ minds. About anything.

Okay, then I will accept that she will keep it open, and hope no one goes to visit while she does (since the time of this interview, the bookstore has indeed closed).

Yep, you kind of have to rely on the city or the province to enact those guidelines. Each day here in Vancouver it seems like another category of businesses is being closed down. Psychologists were Monday. I closed my practice down last week so I’m in tele-health now in my second week. But it was just a few days ago that we got our directive to move to tele-health, from the public health officer who relayed the message through the colleges here in BC.

So it’s going to have to be legislated. Even if it’s a smart thing to do to shut it down, you can’t force anybody to shut it down including family members. Patience is the antidote to anger! You can maybe ask them why they don’t want to close down. Why it’s important to them. Be curious! What are they afraid will happen if they do close down? Maybe you can find out a little more about why they’re doing this instead of just assuming they’re being stupid and ridiculous and being a danger to everybody else.

Be a little curious about what they’re doing because at this point you do want to keep your relationship strong through this. Be supportive and be someone that they can come and talk to when they eventually do have to make that decision. So when they say “I had to close the bookstore” you’re not going to say “see I told you so”.

Christine Korol quick talk front line health care professionals

You have already been working with front line health care providers – doctors, nurses – how are things different for them now?

Everybody’s gearing up while they can, knowing it’s the calm before the storm. It’s hard working around colleagues as they get more anxious. There’s a lot of talk of death, and getting wills in order, fear that they’re not going to have enough protective equipment. Worrying about having to make difficult choices. Worrying about having to care for colleagues who get sick.

I’m hearing all kinds of things right now that health care workers are afraid of. Both from colleagues and patients who might be health care workers that I’m seeing. I work in a lot of hospitals too, myself, so I have a lot of friends there.

As we’re moving toward providing pro-bono psychological services to front line health care workers, what advice would you give psychologists who take this on as they’re making that first contact?

Listening, and asking what exactly people are worrying about. Typically what I’ve been saying at the start of sessions is “there are so many things to be worried about with COVID-19, what are the particular worries that you have? What’s been hard? What’s been stressful? Because it’s not the same for everyone.

I don’t go in assuming that they’re worried about moral distress about making decisions for patients, when they might be worrying about their own safety. You might be surprised at what they’re worried about. This is going to be rapidly evolving, and typically what’s traumatic for people are not the things you would expect. Doing a lot of trauma work myself, I’m always surprised at what causes people to feel bad or guilty.

So asking them to give a good detailed description of what it is that’s stressful for them now. I’m a cognitive therapist so I go looking for ‘hot thoughts’ – what they’re thinking, and then pause and maybe say “I want to stop you – so you think it’s your fault that this went wrong with this particular patient?” So I’ll go looking for places of guilt.

I’m doing a lot of listening now and there are not a lot of people who hear what health care workers are dealing with. They’re going to be grieving, they’re going to be traumatized, and it’s not something they can talk about with friends and family. It’s even going to be hard to talk to colleagues about it because they won’t want to upset anybody else. So therapy can be the one place where they can really have those open and detailed conversations about the things that are causing them distress.

As you said, it’s rapidly evolving. Presumably what’s worrying people today is not what’s going to be worrying them a week from now, or two weeks from now.

Yes, everybody’s kind of mobilizing and getting ready at the time we’re doing this interview. In some areas of the hospital I’m hearing that, for example the ER is very quiet, and the regular public is basically staying away. So it’s eerie and strange, and then it’s going to get busy really fast. Then we’re seeing photos from New York. I saw a photo of a group of nurses in New York wearing garbage bags for protective gear. We’re going to see more images like that and health care workers being really upset.

I’m also right now seeing health care workers being really upset with people walking around and not caring – not listening to physical distancing recommendations. That’s been the theme of the week, actually. Not just with health care workers but I certainly hear that a lot, you know, “don’t people care?” So it’s very hard for them to see that.