Matthew Saks is a clinical social worker in Colorado and oversees a residential facility for adults with severe mental illness and substance use. He also has a small private practice.
Submitted April 26, 2020
Our residential facility is the “least restrictive” level of care. This means that, unlike a psych hospital, our clients come and go freely; they take their own medication; they live very independently in individual rooms. We encourage them to work or volunteer in the community and use their skills. We are a “therapeutic community,” one of only a small number in the country.
Before COVID-19, the lives of my patients were already difficult. Nearly everyone has experienced trauma. Some have come from homelessness. Many fight every day to stay sober. Some are tortured by voices during the day; others are tortured by visions in their sleep. Clients without such severe symptoms might just struggle with the inherent difficulties of being human: anxiety, depression, loss.
The first challenge of COVID-19 was to figure out how to keep our clients safe. We instituted strict hygiene measures and social distancing. We disbanded our therapy groups and moved to a telehealth model. We’ve distributed several rounds of masks. The harder question, though, was how to have a program at all. As a therapeutic community, our guiding theory is that community heals. There is decades of research to support this kind of relational approach, but I would sum it up by just saying: people need people. The most important aspects of our program are our community dinners, therapy groups, group outings, and general socializing.
So how can people connect at a distance? The million-dollar question. I’m still not sure what the answer is. The day after we social distanced, I put up a “gratitude wall” in our front hallway, a big sheet of paper and some markers where community members could express positive sentiments about each other. My friends tease me that things like this are cheesy – #livelaughlove – but they work. Our community members continue to socialize, maybe more than ever. A lot of good conversation can happen at six feet’s distance.
The biggest concern for me during all of this has been becoming a vector myself. I have aging parents and an 8 year-old son. I have asthma. Even with the precautions we’re taking, my exposure is not insignificant. My clients and I all share the same bathrooms and kitchen. We pass each other in hallways. Sometimes close contact is unavoidable. Ever since the pandemic began, I’ve had a low level of anxiety buzzing through me, just under the surface. I’ve been confronted with unanswerable questions of how to balance my responsibility to my clients with my responsibility to myself and my family.
I want to tell one brief story to illustrate this conflict. This past week, I was having trouble reaching a certain client. I had not seen them around for several weeks, and they were not showing up for their scheduled telehealth sessions. Isolation in our setting can be dangerous. I’ve already lost several clients to suicide in my young career and, with COVID-19, I’ve noticed an increase in suicidal thinking in some clients. So, with some trepidation, I put on a mask and went to this client’s room. I knocked on the door. They responded and, through the door, told me they were having trouble getting their phone to work. I really needed to make contact with this client, so I asked if they would meet in my office. They agreed.
I hadn’t met a client face to face in months. When they came in, we positioned ourselves at opposite corners of the room, roughly 6 feet apart. We left our facemasks tucked under our chins. It was hard to talk with them on and frustrating to not be able to read each other’s facial expressions. We colluded to indulge ourselves in a few minutes of face-to-face conversation.
I opened by trying to make some kind of contact with them. I expressed my concern that they had seemingly disappeared for a few weeks. They acknowledged that they had been isolating. We were actually having a real, face-to-face conversation! It felt like slipping into a hot pool. Lovely, maybe a little intense.
They shared with me how they’ve been doing recently. They explained that they had been exhausted because they had been working a lot of hours. Without going into detail, I’ll just say that they were working one of the low-wage and essential jobs that put people at higher risk of exposure to the coronavirus. I had not known that this client was working at all. I immediately put on my mask, but we had already been talking for 20 minutes. I had also noticed them cough a few times during that period. I asked what their exposure was during this job. They told me about the safety precautions that they had been taking. On the other hand, they said that they were still worried that the job was putting them at risk. My heart sank. I had passed the last month living in hypervigilance, disinfecting doorknobs and light switches with Clorox, and now this. I asked if they had experienced any symptoms of coronavirus, and they said no. They did not present as physically ill. But those two coughs…Maybe they were nothing. Maybe? Some good material for me to perseverate on in the middle of the night. We finished our session. I finished up my work for the day and went home.
On my drive home, my body began to shake. My system had had enough of this pandemic. At home I drew a hot bath and stayed there for an hour. When I told my partner she was furious at me for meeting with my client in person. I was furious at myself, but was also able to reflect on the absurdity of the situations I was having to navigate.
This experience also illustrates, of course, the class dynamics of the pandemic. Most of my clients cannot afford to #stayhome. They work the low-wage, essential jobs that keep our country on its feet.
The Psychological Toll
I keep thinking of the well-known expression of Sartre’s: “Never were we freer than under the German occupation.” I take this quote to express how being confronted with death, the deep precariousness of life, can be an intensely quickening experience. With COVID-19, death stalks the land, plucking people at will. We’re not sure who will be spared. This intimacy with death throws us back, in a sense, onto our lives and the truly important questions. What really matters? How do I want to be remembered?
For my part, what I find myself thinking about most are old times with friends. Getting a pint of beer after work. Lingering for hours at a restaurant, lost in conversation. Those simple moments of togetherness. When we’re all able to meet again, I hope I can retain that sense of pleasure and appreciation – for at least a few weeks, or a few months, before it all becomes habitual again.
Some of my best friends are people I met at Vassar. Those friendships have been critical in surviving this time. Whether it’s trading information and ideas or just having someone to lean on, I know I couldn’t get through this time without those people.