Psychological Flexibility in Theory Practice for Clients, Graduate Students, & Clinical Supervisors During COVID-19

Psychological Flexibility in Theory and Practice for Clients, Graduate Students, and Clinical Supervisors During COVID-19

By Deirdre Waters, PsyD and Paulina Calcaterra, BA (l to r)

As quickly as COVID-19 impacted the state of New Jersey, the transfer to remote learning, telehealth services, and digital clinical supervision occurred for doctoral students in clinical psychology. Paulina Calcaterra, BA, is a rising 2nd year doctoral student in clinical psychology at the Rutgers University GSAPP program and Deirdre Waters, PsyD is a NJ licensed psychologist and part-time lecturer at GSAPP. Here is an account of their experience of transitioning to remote learning and therapy services.

Clinical Supervision

Doctoral programs in clinical psychology provide theoretical and applied practice of psychology throughout the course of the program. In the first year of training at GSAPP, students are assigned therapy cases that correspond with foundational course work. The clinical work is supervised in small groups and facilitated by licensed psychologists on the faculty and in the community. The learning process is accelerated by formulating case conceptualizations and presenting videotaped sessions, receiving feedback from one’s supervisor and cohort, and participating in the other group members’ clinical growth and case presentation. Our supervision seminar was Cognitive Behavioral Therapy (CBT), with an emphasis on Acceptance and Commitment Therapy (ACT). ACT highlights psychological flexibility and teaches acceptance strategies, mindfulness, and valued driven actions as ways to promote psychological well bring (Hayes, Strosahl, & Wilson, 2016). As a beginning clinician, Paulina found the clinical supervision seminar helpful. This was her first exposure to clinical work as the therapist in the room and application of theory into practice. Past experiences of therapy as the client and the role reversal was impactful. Paulina appreciated ACT’s humanistic idiosyncratic approach and learning how it applies to treatment goals. Additionally, watching the flexibility and attunement of her supervisor and fellow trainees helped her to develop clinical instincts and provided the opportunity to practice empirically supported techniques. Five months into our weekly CBT group supervision, which met weekly on campus at the Rutgers University Center for Psychological Services, our last on-site group supervision occurred. It was March 11, 2020. Spring break was scheduled for the next week. Prior to each student’s case presentation, we discussed the news of the partial university shut down that had just been announced due to COVID-19. The identified plan was to continue therapeutic services for individual therapy and to continue meeting for supervision in our small group. We discussed spring break plans in relation to accessibility for client care and identified personal concerns about COVID-19. This supervision session progressed in the usual format, clinical cases were presented, videos of therapy sessions reviewed, supervisory feedback provided, and specific CBT/ ACT techniques recommended. Four months now into the pandemic, this normalcy in our supervision seems remarkable to reflect on. Through the years, many supervised students have

experienced personal tragedies, family changes, and lived through national and world tragedies. Monitoring emotional regulation skills, utilization of coping mechanisms, and reinforcing self-care is an accepted part of the supervision process as we help prepare students for a career in psychology. When our supervision group unsuspectingly met for the last time on campus, Dr. Waters did not anticipate the severity of the pandemic nor the associated personal and professional losses for our clients and our supervision group.

Impact of COVID 19 and Transition to Telehealth

Within the next week, the university campus closed, and the graduate students left the New Brunswick area to be closer to family and friends. Clients were contacted and advised of the clinic closing and telehealth services, including phone and video options, were offered. Psychologists, therapists, and graduate students across the country report a similarly quick transition to telehealth. In fact, according a recent American Psychological Association survey (APA, 2020), 75% of psychologists closed their physical offices and began providing remote services via phone or a HIPAA compliant video session. The graduate students appeared to adjust well to the virtual platform for both supervision and for presenting their cases for clients who continued with treatment. Paulina hosted the secure Zoom meetings from her university account and kindly assisted Dr. Waters with any technological challenges. When connections were lost or rebooted, the group responded with ease and flexibility. The digital platform continues to be functional as our work remains remote. The literature has supported clients reporting favorable results for telehealth when it is available (Bischoff, Hollist, Smith, & Flack, 2004; Chen et al, 2019). Clinicians have noted the same challenges as those noted in our supervision process (troubleshooting technology issues, connection disruptions, and a level of required mental focus). Individually and in groups, we attended telehealth trainings, CEU workshops, and reviewed the written material provided to assist in our quick transition to the telehealth platform. Cognitive beliefs about telehealth being suited only for targeted populations (remote areas, housebound clients) and the practice as less effective than in person therapy were no longer held. Emergency legislation (A3860) was quickly passed that increased access to insurance reimbursement of telehealth services and home residence accepted as place seen (American Psychological Association, 2020). It is important to note that a smooth transition to telehealth is likely indicative of privilege. For example, a private space for therapy, reliable Internet connection at home, and technology with the capacity to support video calls, is required. Similarly, the economic privilege of being a graduate student is exclusionary and further promotes class inequality. These dynamics are also true for clients accessing mental health treatment and the ability to adapt to telehealth may reflect the economic privilege in the field of psychology. Despite the relative ease with which many practitioners transitioned to telehealth, the field should continue to have critical conversations about inclusivity and accessibility of services. It is important to listen to the voices of clinicians and clients for whom the current system is not working and learn how we can adapt. Clients who have the most complex and pressing mental health needs in this pandemic may not have the ability to engage in telehealth. Furthermore, given the treatment barriers that have been well documented in our field, it is likelythat access issues have been exacerbated in this time (Cook, Hou, Lee-Tauler, Progovac, Samson, & Sanchez, 2019; Cook, Trinh, Li, Hou, & Progovac, 2016; Kohn, Saxena, Levav, & Saraceno, 2004). As we experience a moment of reckoning with systemic racism and experience two pandemics, COVID-19, and systemic racism, we must also acknowledge how intersecting identities and multiple systems of oppression create disproportionate barriers to mental healthcare among marginalized groups. As we made our transition to telehealth, the group observed how the pandemic produced a range of clinical implications. Some of our clients quickly transitioned to virtual sessions, missing only one scheduled meeting; therapy sessions were held over the telephone and then transitioned to a secure video platform. Other clients terminated therapy abruptly. Each scenario posed challenges and opportunities: clinicians had to develop new skills for communicating support and attunement remotely for the first time. Transitioning to phone or video sessions also provided an opportunity to learn more about clients as we see them in their intimate environments. That has led to insights that Paulina wonders if she and her clients could have ever arrived at in a neutral therapy room. For instance, a moment during which a family member interrupted a client during a session,Paulina saw an enactment of difficult family dynamics and her client’s response in real-time. For those whose clients discontinued treatment unexpectedly, there were self-doubt and

reinforcement of internal events around inadequacy to manage. Our group was encouraged to practice the same techniques they were introducing to their clients, observing the accompanying internal events (thoughts/feelings) without becoming stuck to them, honoring the frustration and uncertainty, and quickly adapt to the changes that were outside of our control. These techniques echo many of the six core processes of ACT, specifically acceptance, cognitive diffusion, being present, and self as context (Hayes, Strosahl, & Wilson, 2016). ACT explains that maladaptive responses develop when we are inflexible, avoid experiencing the present moment, entangle with our cognitions, attach to our narratives about ourselves and the world, and act in ways that do not align with our values (Hayes et al, 2016). As clinicians, it was important to tap into the core processes of ACT to transcend those pitfalls and stay in a helpful state of mind during this challenging pandemic.

Adaptation, Flexibility, and Rewards

As we began to conduct psychotherapy remotely and manage these various clinical demands, it became clear that therapists’ own experiences of the pandemic were impacting their work. Weighing the horrors of COVID, the disproportionate impact on Black, Indigenous, Asian and other communities of color, and all of the injustices that it highlights are overwhelming thoughts to hold. We are all impacted by the pandemic, clinicians and clients alike, to varying degrees and with access to different resources. Learning how to the balance of providing therapeutic care and managing personal painful experiences is a necessary career long skill. In the literature on providing psychological first aid and responding to traumatic crises, it is acknowledged that containment is a core skill for therapists to utilize to stabilize and support those who are suffering (Kraybill, 2018). ACT’s emphasis on mindfulness, authenticity, and acceptance provided tools for sitting in the present moment with clinical concerns and our own processes. Practicing techniques in supervision allows for mastery and induced calmness that could be brought into the therapy sessions. An important element of our supervision group was a consistently held value and practice of incorporating our own humanity into our work. We checked in with each other in meaningful ways and with intention. It was clear that this process was necessary to make our work sustainable. Clinicians’ self-care and capacity for mindfulness allows an increased connection to the present, and ability to help our clients do the same. Additionally, when therapists have multiple privileged identities, it is important to explore and unpack how these privileges enter the therapy room during the supervision hour. ACT also encourages clinicians to de-emphasize the idea that therapists are experts on their client’s experiences, which Paulina has experienced as comforting during this difficult time. Harris (2006) describes how in ACT treatments, therapists “are in the same boat as their clients—so they don’t need to be enlightened beings or to ‘have it all together.”’ He uses the following metaphor to outline the therapist stance: a therapist might explain to a client that it’s “as if you’re climbing your mountain over there and I’m climbing my mountain over here. It’s not as if I’ve reached the top and I’m having a rest. It’s just that from where I am on my mountain, I can see obstacles on your mountain that you can’t see. So I can point those out to you, and maybe show you some alternative routes around them”’ (Harris, 2006, p. 8). The mountain metaphor has been especially helpful and necessary during this pandemic. No amount of training or wisdom that the clinician holds can make this situation less difficult. Whether it is a technical difficulty or any other kind of interruption in the ideal therapeutic situation, clinicians can demonstrate a willingness to accept the limitations of the present moment while remaining engaged and authentic despite not having perfection or control. Both the client and clinician are practicing their abilities to adapt to the chaotic environments of the pandemic, and telehealth, practicing flexibility in the moment together and learning experientially. Furthermore, expanding our mental filters and making room to recognize the joy and positive elements of training and life outside of COVID-19 was another practice in supervision that became very important. Questions Dr. Waters asked included “What is one thing you learned this week?” and students were encouraged to think outside of our clinical training. We shared recipes, community involvement and other fun facts. There was a balance from checking in and expressing shared grief and anxiety with expressing gratitude and hope. This action allowed us to practice concepts that we teach our clients: holding many different truths and aspects of reality at once (even those that are oppositional) and challenging our negative attentional biases by reminding ourselves of things that bring happiness and healthy distraction. We believe that the fundamentals of psychological flexibility have helped us to all navigate this novel

situation. Practicing acceptance strategies on events outside our control, promoting present moment awareness and utilizing defusion to become unstuck as we provide therapeutic care for others. Treatment objectives and goals are being met. Graduate students, clients, and supervisors are adapting to the chaotic environments of the pandemic, and telehealth. Although mental health challenges have been exacerbated by this global crisis, the ability to push forward or stay still inspires hope.

About the Authors

Deirdre Waters, PsyD is a licensed psychologist who has a private practice in Monmouth County. She is also the director of the non-profit the Behavioral Health Institute of Monmouth County, maintains consulting privileges at Jersey Shore University Medical Center and Riverview Medical Center, and teaches as an adjunct at Montclair State University and for Rutgers GSAPP. Paulina Calcaterra is a 2nd-year student at the Rutgers Graduate School of Applied and Professional Psychology Clinical PsyD program. At this point in her training, she is interested in specializing in trauma, gender-based violence, and body acceptance from a psychodynamic and ACT framework.

Works Cited

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