Using existential-humanistic psychotherapy in the treatment of COVID-19 survivors

By Audrey Karabiyik

September 2020

To say 2020 has been an unusual year would be quite an understatement. As a collective human society, we have all experienced significant alterations to our once normal lives. One factor, COVID-19, has played the predominant role in this process, and some individuals have been affected more than others.

My personal experience with COVID-19 has prompted me to write this article so that my fellow counselors will have guidelines for helping other COVID-19 survivors. It is important to note that no evidence-based therapy practices are currently available as the pandemic continues to unfold. Before this, we had not experienced a worldwide pandemic in 100 years.

What is existential-humanistic psychotherapy?

Existential-humanistic psychotherapy helps clients discover their own uniqueness through acquiring a greater awareness of themselves and the world around them. The therapist assists clients by teaching them to see their resistance so that they can have a more meaningful existence. Clients are free to explore which aspects of their lives support their journey and which can be discarded to live a fuller existence. This approach avoids labeling and diagnosing, so the focus can be placed on self-searching and meaning. There are five key goals in existential-humanistic psychotherapy.

• Develop the capacity for self-awareness and understanding the ramifications of freedom of choice
• Create a personal identity and be present for quality relationships
• Search for the meaning, purpose, values and beliefs of life
• Accept normal anxiety as a natural condition of living
• Become aware of death and nonexistence

Where to begin

The COVID-19 symptomology and experience are unique to each individual, so it is important for existential-humanistic psychotherapists to encompass a number of traits.

The therapeutic alliance must be established during the initial visit. First, by adopting an I-Thou relationship with the client, you establish a relationship in which the client is the authority of their personal illness experience and life. Second, by providing unconditional positive regard, your acceptance and support will allow the client the important opportunity to share their subjective experience and reflect upon it. Third, by utilizing empathy, you will permit your client the freedom to share a fuller range of feelings and emotions with you, thus creating a space to deepen their authenticity.

Stages for COVID-19 exploration

Stage One: Life before COVID-19. This is an excellent entry point to begin the I-Thou therapy relationship. The client will start to gain an understanding of your existential-humanistic style. Simultaneously, you have the important opportunity to explore your client’s communication style and level of expressiveness. You will acquire an understanding of your client’s typical lifestyle, level of functioning, and what values and beliefs existed for them prior to the COVID-19 pandemic. Additionally, you can establish the client’s goals and what they wish to achieve during therapy. Questions that may be of help could include:

• Who were you living with?
• What was your typical day?
• Were you actively employed? How important was your job to you?
• How did you spend your free time?
• How was your general health?
• Did you take time for yourself?
• What was your “normal”?
• What did you value most at that time?

My normal was living with my husband and son. My husband had endured six months of cancer treatments in another country the year before, and we were finally able to live together again. I was working in a counseling capacity. Our spare time was usually spent being with family and friends, traveling and enjoying our personal hobbies. 

Stage Two: Understanding the client’s early illness. In this stage, each client recalls and shares their unique symptomology and experience. At this point, your client may have greater comfort in the therapeutic relationship as a result of you engaging in active listening and empathetic techniques. You teach the client to explore their problem to develop insight by sharing physiological and psychological feelings related to their early illness.

Questions that may be of help could include:

• How did the disease manifest itself?
• What were your early symptoms?
• Where do you think you came into contact with the disease?
• When did you realize you were seriously ill?
• What action did you take to address your illness?
• What were you thinking and feeling about your symptoms?
• What were your concerns at that time?

My symptoms — dizziness, cough, a heightened sense of smell, kidney pain and extreme fatigue — started in late March. My doctor prescribed an antibiotic and suggested I avoid the emergency room because it was believed that all in-house patients were positive for COVID-19 at that time, and if I did not have COVID-19, I would surely acquire it when I arrived. (It was days later that I understood her logic).

So, I spent a few days in bed, sleeping most of the time. I made every attempt to avoid the kitchen because the cooking odors were overwhelming to me. I had a desire to indulge in very hot baths, but each one seemed to make me weaker than the one before. I was feeling unsettled at this point because of the inconvenience of missing work. I also had feelings of fear that things would worsen. 

Stage Three: Determining the client’s level of illness. This stage involves the realization of a more serious illness, worsening symptoms and the eventual need for a higher level of care. Ideally, your client will be able to express a broadening range of feelings and thoughts as they reveal how they came to terms with their level of illness. As the therapist, you can begin to introduce the concept of freedom of choice in their decision-making.

Questions that may be of help could include:

• How long had you been sick by this point?
• What were your worsening symptoms at this time?
• What made you decide to seek additional care?
• How did you discover that you actually had COVID-19?
• How long were you in the hospital?
• What were you thinking and feeling when you realized what was happening?
• What were your concerns at that time?

As part of four days of deepening symptoms, I had ceased all eating and drinking. I was unable to consume anything, mostly due to my heightened olfactory symptoms. Simultaneously, I was beginning an insidious decline in my ability to oxygenate my lungs, so I finally had my husband take me for the inevitable drive to the emergency room.

We were met outside the hospital by a front-line health care worker in complete personal protective equipment. My husband was required to leave before I was permitted to enter the emergency room. In these early days of the pandemic, with only a limited number of cases being discussed in the media, the seriousness of the disease was not yet widely known, but the possibility existed that I might never see my husband again. Although we had both experienced the fear and sadness of my husband leaving for cancer testing and eventual diagnosis the prior year, I believe we both inherently knew that my departure was unlike anything we had encountered before.

Stage Four: What were the client’s experiences during their care?'

While this stage addresses what was happening physiologically with the client, it is also giving birth to several key existential concepts for early exploration. As COVID-19 patients spend time in the required isolative ICU, anxiety rises and universal themes such as freedom of choice, isolation, meaningless and death are thrust upon them, becoming inescapable.

First is exploring the meaning of illness itself while having to grapple with giving up control. Second is finding meaning in the aloneness they are experiencing. Some clients may find that this is the first time in their life they have ever been alone or had an opportunity to focus solely on themselves. Third is finding meaning in the emptiness of their surroundings. Fourth is dealing with finding meaning in life itself and coming to terms with potential death.

You (as the therapist) can openly discuss the reality of death at this stage. Active listening and unconditional positive regard are of the utmost importance during this stage because this is where the transformation ultimately begins. The client deserves to have the complete freedom to share all of their thoughts, memories and feelings, no matter how irrational they may seem to you.

Questions that may be of help could include:

• Did you understand what was happening medically?
• What were your emotions during early care?
• Was this your first experience with emergency care?
• How did you feel when you realized that you had to give up full control to the medical staff?
• What treatments did you receive?
• Did you require the use of a ventilator?
• What was your length of stay?
• What emotions and feelings came into play? Were you frightened? Bored?
• How did you feel being all alone?
• What were you thinking and feeling when you realized what was happening?
• What were your concerns at that time?
• Did you think you were going to die?
• How did you deal with that thought?
• Did you draw any conclusions?

During my first career, I spent many years as a front-line health care worker. Therefore, in the hospital setting, I was returning to my roots and was fully aware of what was happening. With that said, too much knowledge can also prove frightening. I was quickly made aware of the gravity of the situation, and I was well aware that the best approach was to instantly give up control so the staff could make every effort to save my life.

I spent the next two weeks in ICU, continuously receiving 15 different medications, mostly intravenously, and 24-hour-a-day oxygen therapy, as well as undergoing many venous blood and several arterial gas tests and portable chest X-rays. My oxygen levels were very low and not responding to treatment.

The realization had long since set in for me that I would not have visitors and that death was a possibility. My entire focus went to one thing: continuing to inhale and exhale repeatedly, even as COVID-19 played tricks to convince me to stop breathing. A ventilator was considered, but I knew there would be an 85% chance of never breathing on my own again. Each labored breath represented many things — avoiding the ventilator, returning to the presence of my husband and son, lying in my own comfortable bed, not dying alone.

Despite my desires to return home, I spent many hours in the ICU contemplating the life I had lived and the possibility of death. I reconciled my life with God and was in a place of total peace. I came to terms with all of the relationships in my life, feeling sorry for those individuals incapable of making true connection. I was filled with extreme gratitude for what I had been provided throughout my life, including family, special friendships and the ability to connect with others.  

Stage Five: Post-hospital healing and meaning. Checking out of the hospital left me with immense hope. I had achieved what I had set out to do there. At this point, I was still on oxygen 24 hours a day and was able to walk about 24 feet before exhaustion set it. Because little information was available, the doctors required me to quarantine alone for another week, then another. I came to the realization that all one can do for the sick or terminally ill is to provide sustenance and let the person know they are loved.

Two weeks alone in my bedroom and my perspective had changed again. My wonderful bed had become my new prison. But, finally, I was set free of isolation and able to experience smiles, laughter, human touch, hugs and togetherness again.

Stage six: Where do we go from here? Certain clients will benefit from cognitive behavior therapy at this point to explore any distortions that may exist and will become content with their progress, thus ending their therapy at this time.

Others, having been given the opportunity to unleash their personal COVID-19 journey, will begin to open to possibilities for the future. First, you can explore anxiety with the client. You can provide psychoeducation to help the client understand the purpose of anxiety and to distinguish between existential, normal and neurotic anxiety. You can then explore how freedom of choice is used in decision-making and relates to the future and discuss the reality of death in greater detail. Introduction of Maslow’s hierarchy and self-actualization can provide the client psychoeducation to increase their self-awareness in the present and give them a road map for the future.

Questions for possible exploration can include the following:

• Do you see yourself differently since your illness?
• What things did you learn about yourself?
• Are you more comfortable with yourself at this time?
• Have your values or beliefs changed in any way?
• Have your thoughts or fears changed related to death?
• Are there any changes you would like to make in your life?
• How would you like to spend your time in the future?
• Will you handle situations differently?

Lingering COVID-19 symptoms, including bouts of low energy, occasional low oxygens levels and the unfortunate loss of a great deal of hair, still plague me. However, they are insignificant compared with my desire to help recovering COVID-19 survivors and front-line workers find meaning in their personal experiences.  

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I would like to thank Ayala Winer and Arlene Gordon for their gentle guidance in encouraging me to share my story.

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Audrey Karabiyik is a graduate of Nova Southeastern University and is currently a registered mental health counselor intern in Florida. She is starting several COVID-19 groups geared toward survivors, front-line workers and others wishing to process the “new normal.” She is associated with Systemic Solutions Counseling Center in Plantation, Florida. Contact her at AudreyKarabiyik@gmail.com.

The views expressed in Counseling Today are those of the authors and contributors and may not reflect the official policies or positions of the editors or the American Counseling Association.