In the Aftermath of the Pandemic Interpersonal

Psychotherapy for Anxiety, Depression, and PTSD 1st Edition

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 CONTENTS

Introduction: The Pandemic

1. In the Aftermath of Upheaval

2. How the Pandemic Has Transformed Psychotherapy: Remote
Treatment
3. Interpersonal Psychotherapy: Life Event–Based Therapy
4. Life Crises: Grief, Role Disputes, and Role Transitions
5. Major Depression
6. Posttraumatic Stress
7. Anxiety and Other Distressing Symptoms
8. Termination
9. Dealing with Post-Catastrophe—Resilience

Acknowledgments
References
Index
 Introduction
The Pandemic

In 2020 the world suddenly and seemingly irrevocably changed. The Covid-
19 virus, previously unknown, often lethal, and without a treatment, began
to devastate populations around the globe. In the absence of a vaccine,
societies retreated to ancient patterns of plague control, namely social
distancing. This physical isolation protected individuals, kept intensive care
units (ICUs) from overflowing, and limited at least the speed of infection—
but at a cost.
The anti-Covid lockdown in the United States saved lives, at least in
parts of the country that obeyed it. It brought with it, however, a host of
problems: loss of sense of health safety, and sometimes loss of health itself;
loss of daily routine, loss of social support, loss of income, often loss of job,
and sometimes loss of loved ones (see Table I.1). These losses, alone and
combined, contributed to the next and, we fear, enduring wave of pathology
during the spread and in the wake of the Covid-19 virus. We anticipate, and
seem already to be seeing,1 psychopathology on a grand scale: anxiety,
depression, traumatic stress, and substance misuse. Those who haven’t died
or become physically ill still suffer.
In the midst of this pandemic, our team of psychiatric researchers at
Columbia University/New York State Psychiatric Institute (NYSPI) sought
to provide remote (virtual, phone and internet video) treatment to patients in
need. Remote therapy is itself a major adjustment for therapists used to
seeing patients in person.2 And a major adjustment for patients, too.
Moreover, it was unclear whether the treatment lessons we had learned
from other traumatic events, such as rape, war, the September 11 attacks,
and natural disasters like hurricanes and earthquakes, applied to this
catastrophe. Most traumatic events are, thankfully, brief, whereas this
pandemic is (as I write in May 2020) already a siege that promises to
continue. Prolonged stress is more distressing and becomes more engrained
than acute stress.3 The longer it continues, the worse the effects. And while
the Covid-19 “plague” is an impersonal trauma, which is comparatively less
distressing than interpersonal trauma,4,5 its extreme interpersonal
consequences compound its damage.

Table I.1. Losses Due to the Covid-19 Pandemic Engender

Psychiatric Symptoms
Loss Threat Consequences
Loss of security Potentially lethal viral infection Fear of or actual illness ➔ anxiety,
Frontline medical and other personnel pain, PTSD, depression, anxiety
witness trauma
Loss of income Anxiety about rent, food, finances Anxiety, depression
Loss of Damage to career, income Anxiety, depression
employment
Loss of loved Complicated mourning Traumatic loss; disrupted mourning
ones rituals ➔ anxiety, depression, PTSD
Loss of routine Home lockdown Disrupted social rhythms, activities,
pleasures → anxiety, depression
Loss of social Physical distancing can mean social Social isolation → anxiety,
support isolation depression

A further layer of interpersonal malignity magnifies the effects of

coronavirus. From the start of the pandemic, Americans have seen other
countries, led by unifying, compassionate leaders, take orchestrated,
scientifically driven steps to combat the spread of infection, with often
beneficial results. In contrast, the U.S. federal government has been
divisive, attacking, openly racist at a moment when racial and ethnic
minorities are hardest hit, and strikingly anti-scientific. The President of the
United States has recommended unproven and dangerous remedies such as
injecting bleach (!) and turned wearing a mask into a political statement
rather than a public health measure. The federal and many state
governments have failed on many levels, for many people, their leaders
pointedly ignoring and discounting a rising plague in defiance of basic
medical tenets. Spike Lee made the point in his 2006 film When the Levees
Broke that although Hurricane Katrina was an impersonal trauma, the
failed, racist governmental response to the disaster gave it added
interpersonal insult.
Amidst the pandemic, in the anticipation of a polarized national election,
there has been a sudden explosion of national awareness and protest about
structural racism following airings of videotaped evidence of the killings of
George Floyd on May 25, 2020, and other African American men and
women, by white policemen. The Black Lives Matter movement is a
healthy, belated response to centuries of inequality and mistreatment, and
its invigoration seems a healthy channeling of the frustrations of months of
lockdown into an idealistic cause. Dealing with structural racism is an
important cause, albeit not the focus of this book. Nonetheless, all this
change adds to the turmoil in the environment individuals face.
Moreover, this is only the first wave of virus, and first aftershock of
psychiatric symptoms. If there are future waves, as it appears there may
well be, they will likely compound the psychiatric sequelae. What effect
will this pandemic have not only on the adults who lose their jobs, but also
on their children who are evicted from their schools and separated from
their friends for months on end? Even after a vaccine arrives, the
psychiatric consequences of this global disaster will likely be long-lasting.
This book describes the application of interpersonal psychotherapy (IPT)
to treating the psychiatric consequences of Covid-19, and more generally to
any terrible social disaster. IPT is one of many psychotherapies, and it is
surely not the only route to treating post-Covid psychological symptoms,
but many therapists and patients may find it a particularly useful approach.6
I will explain why in a moment.
Most books on IPT have followed a research data stream. Almost every
IPT adaptation for a particular psychiatric disorder has been empirically
tested and shown to work before it has been disseminated. We know that
IPT benefits people with major depressive disorder (MDD),7,8 bipolar
disorder (adapted as interpersonal social rhythms therapy [IPSRT]),9 eating
disorders,7 and posttraumatic stress disorder (PTSD).3,10,11 What we don’t
entirely know is how much it helps people who develop distress,
depression, or PTSD in the wake of a prolonged disaster such as the Covid
pandemic. We hope that the National Institute of Mental Health, which has
in recent years funded neuroscience at the expense of clinical research,12
will recognize the need for immediate clinical trials as a result of the mental
health fallout of the pandemic. Nonetheless, as we await research evidence,
IPT appears to be a good candidate for the psychiatric consequences of
disaster. All of the treatment cases described in this book, while disguised to
protect patient confidentiality, are actual presentations from the pandemic.
 Why should IPT work in the setting of disaster? First, IPT has been
shown to alleviate MDD and PTSD, two of the most common sequelae of
traumatic life events, and to lower anxiety. Second, IPT is a life event–
based therapy, using life circumstances to contextualize psychiatric crises,
explain strong emotional reactions, and use understanding of those
emotions to negotiate interpersonal and other life difficulties.7 The worse
the life circumstances, the more understandable strong feelings become. A
pandemic is surely a life event, and it brings other distressing events—
unemployment, financial need, strained interpersonal relationships, etc.—in
its trail. Third, IPT focuses on mobilizing interpersonal support and on
repairing attachment.13,14 This makes it an appropriate intervention for a
time of interpersonal isolation, when physical separation threatens to
deprive individuals of needed social support.6 Social support is a key
protection against anxiety, depression, PTSD, and psychic and medical
vulnerability more generally.5 Fourth, the loss of daily structure contributes
to people’s disorientation and discomfort during the crisis. Adding
components of social rhythms therapy (from interpersonal social rhythms
therapy15) can help to restore the lost structure of pre-Covid daily life.
People often don’t like to have strong feelings, particularly negative
feelings. Because of that discomfort, they often try to minimize their
feelings through intellectualization, distraction, or suppression. The Covid
pandemic inevitably evokes powerful feelings, and particularly “negative”
affects such as anxiety, anger, and sadness. Some of these feelings are
appropriate to the situation, others excessive. A precept of IPT is that
feelings are important and informative: it is better to know how you feel,
and why, in order to respond to life’s situations. It’s important to recognize
that painful affects can be normal: they reflect a painful environment.3
When feelings go unrecognized and detached from context, they can
become a confusing additional internal pressure for an individual to
struggle with.
All of these features suggest IPT as a helpful counterweight to the
stresses of the pandemic.6 We are using IPT at Columbia/New York
Psychiatric Institute as well as in private practice to assess its benefits, and
thus far it seems quite helpful. I hope that the reader, who is likely a
psychotherapist treating patients with various emotional and psychiatric
responses to these painful events, will agree.
 John C. Markowitz, MD
May 2020

An update at the completion of the text: three months later, Covid-19 has
not begun to disappear. While New York is no longer the American
epicenter of the virus, more than three million Americans have already been
infected, more than 130,000 have died, and the daily number of new
infections is rising. We are in for a longer siege than anticipated, with
growing psychiatric consequences.
July 2020
 1

In the Aftermath of Upheaval

Our environment shapes us. Here in the United States, protected by two
broad oceans, we had long been spared threats of invasion. Geography may
have fostered a sense of security that partially explains the long-standing
American ethos of confidence.16 Things have become shakier of late,
however, since the September 11, 2001 attacks and now the invasion of an
invisible, potentially lethal killer. As the world becomes more threatening,
we feel more threatened.

THE DISASTER
Beginning in March 2020, the country and the world turned upside down.
Americans began dying in incomprehensibly large numbers—more than
100,000 before the end of May. Many who didn’t die became seriously and
chronically ill. The symptoms of Covid-19 took a while to fully appreciate,
but it quickly became clear that acute respiratory distress often required
ventilator support, and hospital ICUs became overloaded. With closed
borders disrupting supply lines, a shortage arose of personal protective
equipment (PPE) such as face masks and gloves, as well as access to viral
testing. In the finest, most sophisticated hospitals in the world’s richest
nation, doctors, nurses, and other staff were forced to reuse PPE, often
inadvertently infecting patients and themselves. Bodies have piled up in
refrigerated trucks as morgues have overflowed. The initial public reaction
was, understandably, fear (albeit, in some quarters, denial).
Frontline medical workers are facing particular risk of infection. Poorer,
minority communities, with denser housing and poorer access to treatment
and whose work often put them at risk for contagion, are suffering
disproportionate illness and death. So are the elderly, particularly debilitated
individuals clustered in nursing homes, and inpatients in psychiatric
hospitals.
While medical professionals around the country and the world have
pulled together impressively to provide patients supportive treatment of
Covid-19 symptoms and to study potential treatments and vaccines, the
infection has no immediate cure. Protecting lives hence requires isolation,
quarantine, and social distancing. When the virus struck, businesses,
restaurants, and entertainment closed. The economy ground to a near halt.
Unemployment figures in the United States reached almost forty million
(40,000,000) in a matter of weeks, with unemployment rates rising from
3.5% to almost 15%. People worried about how to pay the rent and to
obtain food to eat. Food banks were overwhelmed by miles-long lines of
cars. The federal government’s response to this catastrophic situation was
and (months later!) remains disorganized, inadequate, and often
counterproductive, leaving each state to fend for itself. It has been shocking
and surreal to see New York City shift abruptly from bustling megalopolis
to sci-fi ghost town (Figure 1.1).
Figure 1.1 Times Square, March 31, 2020.
Photo by the author.

Many frontline individuals caring for patients are risking their own lives
and witnessing horrible events and deaths, the “Criterion A” of the fifth
edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) traumas that qualify for the diagnosis of PTSD.17 Compounding
this has often been a sense of moral injury that lack of supplies and of
governmental support is sabotaging their work and putting their patients’
and their own lives at unnecessary risk.18
Even the many Americans who have had asymptomatic infection or
avoided the virus suffer. There has been a torrent of upsetting news,
evoking upsetting feelings. Each of the medical and social stressors listed in
Table I.1 would have sufficed to produce high levels of anxiety in the
general population and, as time has dragged on in months of isolation, to
breed frustration and depression and eventually boredom from the
monotony. The pent-up frustration may have contributed to subsequent
crowd violence. Attempts at the “reopening” of limited social life and
business, a seemingly encouraging development, have brought new fears
and realities of infectious spread. Two other central factors have extended
from and compounded the anomaly of the situation: the social and
economic lockdown required by social distancing disrupted social rhythms
and social support.

Disruption of Social Rhythms

Part of what makes normal life normal is a familiar daily routine. Most
people fare best waking up at the same hour every morning, sitting down to
coffee and breakfast; then commuting to work, interacting with colleagues,
and following work protocols until the time comes to return home. Then
preparing dinner, eating, and spending time with one’s family, perhaps
watching television or reading before heading for bed—again, often at a set
hour. The temporal and behavioral landmarks of such a day, termed social
zeitgebers, or “time givers,” help give us our social role and orient us to the
environment.19 Such social rhythms provide a comfortable psychic
structure to the day as well as conditioning a regular, healthy somatic sleep
cycle.
We all rely on these patterns. Individuals with bipolar disorders are
particularly sensitive to such daily stimuli, which is why interpersonal
social rhythms treatment (IPSRT)9,15 was developed for their treatment.
Disrupting familiar life patterns is disorienting and anxiety-provoking,
particularly when the pattern shifts very suddenly for the whole population.
Who am I if I’m not going to my job? How do I define my day and week if
I’m stuck at home all the time? During the lockdown, not just personal
patterns but also larger social patterns ceased. Public spaces and activities
closed. There were no longer sports scores to check. Outside entertainment
and restaurants shut down. Stores closed or had limited access, leading to
runs on toilet paper and other supplies because things we took for granted
could no longer be so.
While some individuals who could still work from home initially felt
pleased not to have to commute, for many this pleasure quickly waned.
Days lost their structure. There was no longer a boundary between work
and home life, making it hard to unwind from stressful work. Parents whose
children’s schools had closed struggled to work (if they still had work),
teach, and simultaneously provide child care in the course of the day.
College students were forced to return home, feeling cheated of their
collegiate experience, distanced from their classmates, and unhappily stuck
with their families at a moment of expected independence. With the
breakdown in routine, many people began to feel disoriented and
uncomfortable: “surreal” was an adjective frequently used. Life was no
longer normal, and the abnormality was unnerving. With limited options for
activity, people grew increasingly frustrated and bored.
These disruptions in schedule frequently interfered with and disrupted
sleep schedules, leaving people tired, more irritable, and more anxious. All
this disruption is fertile soil for distress and psychopathology.

Social Distancing and Social Support

The requirement to “shelter in place” meant having to stay home. This
physical isolation of quarantine tended to cut people off from friends,
family, and work colleagues, from confidants and acquaintances. Thus
physical isolation risked loss of social support. As people are social
animals, this isolation was palpable. Zoom parties and phone conversations
compensated a bit, the “seven o’clock cheer” that rang through cities every
evening to salute healthcare workers provided a bit of communal solidarity,
but mostly people felt cut off.20 Even when meeting in person, behind
masks and gloves, six foot social distancing meant the absence of physical
contact; people missed hugs and kisses.
Social support is a crucial factor in mental and even physical health.5,21,22
Social isolation has been linked to physical decline and premature death.23
Social support means that you do not feel alone, that if you have problems
and strong feelings you can share them with others, rather than keeping
them in as painful secrets. Feeling anxious or depressed by various losses or
other aspects of the pandemic, people were (and remain, at this writing)
threatened with loss of part of the security system that stabilized their lives.
Everyone has suffered, but people with already limited social support,
already at higher risk for psychiatric symptoms, have suffered more.
A further problem has arisen. In the absence of the usual patterns of life,
many people have turned, understandably, to virtual life. The internet
provides endless diversion, news, fake news, and social media contacts to
those who seek them. Keeping track of some news seems only healthy, to
know what is going on so as to be able to respond. Yet it has become clear
that too much social media use is a risk factor for psychiatric symptoms,
ranging from anxiety to depression to suicide risk.24,25,26,27,28,29,30,31

THE SECOND WAVE: PSYCHOPATHOLOGY IN THE WAKE OF

THE PANDEMIC
Thus, overnight, normal life became extremely abnormal. It remains so
months later. Essentially everyone has felt stresses and suffered losses,
generating anxiety, sadness, anger, and other feelings. Some of that has
been warranted: anxiety, based on fear of infection, fear of an uncertain
future. Sadness, reflecting loss. Anger at the frustrations of a circumscribed
life, at missed opportunities, and at others in a crowded household living
one on top of another. Although most people are resilient in adjusting to
stressors, finding some way to roll with the punches, a substantial subset
will suffer symptoms (Figure 1.2). The greater the concatenation of
stressors, and the longer they persist, the greater the likelihood and severity
of psychiatric symptoms.

Figure 1.2 Psychological fallout of the Covid-19 pandemic.

Our PTSD team at Columbia University/NYSPI, led by my colleague

Yuval Neria, PhD, remembered the psychiatric aftereffects of the September
11, 2001 World Trade Center attack and became immediately concerned
that the viral pandemic would trigger a large and long-lasting second wave
of psychopathology.32 In retrospect, 9/11 was a brief if horrific trauma, yet
its scars persist to this day. While most people adjusted to it, individuals
vulnerable to trauma (based on prior trauma, genetics, or psychiatric
history) or severe exposure to the trauma (e.g., proximity to the World
Trade Center, knowing someone who died in the towers) developed PTSD,
major depression, substance misuse, or some combination of these.33 In the
current pandemic, we felt there were just too many stressors, too many
losses, affecting the entire populace for too long. Even as the first viral
wave seemed to begin to recede, a new wave of psychiatric disorders was
likely to follow.
Disorders could result from stressors or possibly even from central
nervous system effects of Covid-19 infection itself.34 Frontline clinicians
trying to provide care face high risk. An upsetting headline in New York
City on April 27, 2020 was the suicide of Dr. Lorna Breen, the forty-nine-
year-old medical director of the emergency department at New York–
Presbyterian Allen Hospital in Upper Manhattan, an epicenter within the
epicenter of the viral assault.35 Dr. Breen had contracted Covid-19, gone
home to recuperate for some ten days, and then perhaps rushed back to her
emergency room (ER) service too soon. She again witnessed scores of
unpreventable deaths in an overwhelmed system. The hospital again sent
her home, after which she killed herself.

HOW SHOULD YOU FEEL?

Context matters: life events have emotional consequences. In a moment of
great tumult, feelings grow tumultuous too. Anxiety is a normal response to
threat, and the pandemic is a threat. Sadness is a normal response to loss,
and people are suffering losses. Anger is a normal response to frustration,
and these are frustrating times of curtailed lives. As psychotherapists surely
know, people often have difficulty gauging whether their feelings are
appropriate, whether they can trust their own feelings. Most of us do not
like strong affects, and particularly negative affects. Under such novel and
unpleasant circumstances, it is small wonder that people would struggle to
tolerate their emotional responses.
It is crucial under such circumstances to distinguish between signal
anxiety as the alert to a threat and symptomatic anxiety as an excessive