The Clinical Angle: Agency and Communion in the Time of Pandemic.
Tilda Cvrkel & Thane Erickson
For most clients – and clinicians – 2020 was an agonizing year. The twin pandemics of COVID-19 and state-sanctioned, systemic racism provided the backdrop to our clinical work. As we begin 2021, we find ourselves still in the thick of both. This period has brought increased anxiety, depression, and isolation (Salari et al., 2020), and further deepened social inequalities (Clouston et al., 2021). As clinicians with an interpersonal bent, we suggest that the metaconcepts of agency and communion help us understand, and perhaps address, some of the challenges of the moment. First described by Bakan (1966), agency encompasses differentiation, autonomy, and power, whereas communion reflects connection, intimacy, and group cohesion (Dawood et al., 2018; Horowitz et al., 2006; Wiggins, 1991). Our attempts to provide free integrative cognitive behavioral group therapy online during this past summer revealed the unique current clinical and ethical challenges to fundamental needs for agency and communion as well as ways we might help foster them in those we serve.
The pandemic has clearly created challenges to communion. The most striking impact to communion in the therapy room is that most of us no longer use a therapy room. Many of us have pivoted to teletherapy, meeting our clients in boxes on screens instead of couches in offices (Pierce et al., 2021). Telehealth creates opportunity for us to support clients in a deeply destabilizing time, providing a steady presence when most of life is not. But the format produces unique interpersonal difficulties, restricting many of the tools we use to establish alliance and connection. For instance, we now typically see clients only from the shoulders up, prohibiting reading of body movements and the mutual interpersonal regulation that more easily occurs in person. And goodness knows there are technical difficulties, such as a Zoom connection glitching during a particularly intimate disclosure. We sometimes found it hard to discern the interpersonal styles and impacts of group members who walked around their apartments while on camera or turned off their camera (e.g., such behaviors can indicate dominant or cold social acts or merely difficulties with the online format). Genuine communion involves a dyad or group in sync with one another, a union of shared goals and experience. This is not always possible with the partially disembodied nature of telehealth. In the best of cases, it can be hard for clients to shift into “therapy” mode in their home space given the demands of kids, pets, and partners. Like many clinicians, we have conducted teletherapy sessions with clients in cars, sidewalks, or a children’s playhouse, the only quiet spaces they could find.
Teletherapy also raises ethical challenges to agency in this sphere. The therapeutic relationship is built on a consensual expectation of confidentiality out of respect for the agency and autonomy of our clients. Teletherapy complicates that. Though we use HIPAA-compliant teletherapy portals, anything transmitted online is less secure than our closed-door offices. More immediately, many of the interpersonal struggles our clients face concern the people with whom they share living space. This has become more pressing with stay-at-home orders and social distancing. We have clients who live with abusive partners, for example, and LGBTQ clients forced back into non-affirming parental homes. Therapy should provide a lifeline for people in heightened interpersonal stress, but the realities of sharing limited space means fewer safe or private spaces for clients to speak honestly about their concerns. This puts our clients at risk should an unintended audience overhear our sessions. In a group context, there are additional challenges (Weinberg, 2020). When group members participate in their homes and private spaces, clients can’t know who is within earshot of other group-member’s computers, further increasing the risk of unintentional and nonconsentual disclosure.
Despite such clinical challenges, centering on the tension between agency and communion (Bakan, 1966; Horowitz, 2006) helps us appreciate and navigate the background conditions of our clinical work. As the world experiences the COVID-19 pandemic, so too must we face the realities of racism and social injustice. As with the coronavirus, the harms of injustice are not equally distributed. While there is beauty in common experience and realizing that we’re not alone in our struggles, uninvited or inappropriate attempts at agency or communion can generate frustration, anger, or disgust (Hopwood et al., 2011). Attempts to create unwelcome communion or deny people rightful agency can also be a source of ethical harm. This is no different in the therapy room, and we are obligated to think about how to navigate power and agency imbalances in our spaces.
We live in Seattle, and our city held massive protests against racist police brutality—which we viewed as agentic strivings in a communal form—nearly every day of the summer. We ran several transdiagnostic anxiety disorder therapy groups during these months, each group diverse in age, gender, race, sexual orientation, and political leanings. Group members felt differently about the protests, and we were challenged to build group cohesion or “we-ness” (i.e., communion) amidst this social backdrop. Although imperfectly, we strove to maintain a creative tension between agency and communion.
With regard to agency, we noticed twin temptations to discuss political differences as well as to ignore divisive topics to prevent a rupture in the group. Neither of those felt like the right choice. For some members of our group, this was a merely intellectual discussion. To them, Black Lives Matter (BLM) is one possible position among many—something to debate like tax rates. For other members, BLM is a call for the most basic of human rights. There are very different stakes in this game. Genuine communion requires taking on the stakes of others, and that is not always possible in time-limited engagements. Permitting intellectual debate over BLM would involve asking for very different levels of cost and vulnerability from different members, without the consent of the people asked to bear the highest cost. As clinicians, we have ethical obligations not to allow our therapy to reproduce and perpetuate social harms. Honoring group members meant pulling back on communion and pushing forward on agency at times. And so we did, spending time talking about the city’s events with clients individually before coming together as a group. When clients needed to process experiences that put them in marginalized or non-consensually vulnerable positions within the group, we used breakout rooms to facilitate such processing prior to returning to group tasks. Drawing upon the Structural Analysis of Social Behavior (Benjamin, 2011), this strategy could be framed as clinicians granting and clients taking autonomy in place of group dominance versus submission exchanges. Other strategies to empower included modeling and normalizing explicit disclosure of identities and pronouns for those who chose to share. Also, we used in vivo and imaginal exposures targeted to increase agency and self-efficacy. Members high in social anxiety helped run the group and decide on break length. And as each individual practiced during sessions in order to gain mastery over their deepest fears, they were cheered on by the group, a uniquely communal process to support individual agency.
To foster communion in our online groups we adopted strategies such as eliciting disclosures about shared fears. As clinicians, we somewhat exaggerated our nonverbal expressions and gestures to invite active engagement, and monitored the chat function to incorporate chat comments into the larger dialogue. The format of seeing into each others’ living spaces further fostered connection, as we introduced our canine and feline family members to each other. We laughed together at unexpected “Zoom-bombing” by clients’ children. Moreover, as an exposure-based therapy, we incorporated as many shared exposures as we possibly could. In vivo exposures that would normally only be witnessed by the clinican, or done as homework between sessions, now happened in group. When one group member worked on a difficult exposure around wearing unpreferred clothing, other group members spontaneously changed into matching outfits as support. When one member practiced receiving compliments from the group, the group insisted this become a regular event every session, picking a different “love bomb” target each week.
Being mindful of the dance between agency and communion serves us well, even online during difficult times. More importantly, it allows us to better serve our clients.
About the authors:
Tilda Cvrkel is an ethicist (UCLA) currently working on her second doctorate in clinical psychology at Seattle Pacific University.
Thane Erickson is a professor of clinical psychology at Seattle Pacific University
References
Bakan, D. (1966). The duality of human existence: Isolation and communion in Western man. Boston, MA: Beacan Press.
Benjamin, L. S. (2011). Structural analysis of social behavior (SASB). In L.M. Horowitz & S. Strack (Eds.), Handbook of interpersonal psychology: Theory, research, assessment, and therapeutic interventions (pp. 325-342). Hoboken, NJ: John Wiley & Sons.
Clouston, S. A. P., Natale, G., & Link, B. G. (2021). Socioeconomic inequalities in the spread of coronavirus-19 in the United States: A examination of the emergence of social inequalities. Social Science & Medicine, 268, 113554. https://doi.org/10.1016/j.socscimed.2020.113554
Dawood, S., Dowgwillo, E. A., Wu, L. Z., & Pincus, A. L. (2018). Contemporary integrative interpersonal theory of personality. In V. Zeigler-Hill & T. K. Shackelford (Eds.), The SAGE handbook of personality and individual differences: The science of personality and individual differences (p. 171–202). Sage Reference. https://doi.org/10.4135/9781526451163.n8
Hopwood, C. J., Ansell, E. B., Pincus, A. L., Wright, A. G. C., Lukowitsky, M. R., & Roche, M. J. (2011). The Circumplex Structure of Interpersonal Sensitivities. Journal of Personality, 79(4), 707–740. https://doi.org/10.1111/j.1467-6494.2011.00696.x
Horowitz, L. M., Wilson, K. R., Turan, B., Zolotsev, P., Constantino, M. J., & Henderson, L. (2006). How interpersonal motives clarify the meaning of interpersonal behavior: A revised circumplex model. Personality and Social Psychology Review, 10(1), 67–86. https://doi.org/10.1207/s15327957pspr1001_4
Pierce, B. S., Perrin, P. B., Tyler, C. M., McKee, G. B., & Watson, J. D. (2021). The COVID-19 telepsychology revolution: A national study of pandemic-based changes in U.S. mental health care delivery. American Psychologist, 76(1), 14-25. http://dx.doi.org.ezproxy.spu.edu/10.1037/amp0000722
Salari, N., Hosseinian-Far, A., Jalali, R., Vaisi-Raygani, A., Rasoulpoor, S., Mohammadi, M.,
Rasoulpoor, S., & Khaledi-Paveh, B. (2020). Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: A systematic review and meta-analysis. Globalization and Health, 16(1), 57. https://doi.org/10.1186/s12992-020-00589-w
Weinberg, H. (2020). Online group psychotherapy: Challenges and possibilities during COVID-19—A practice review. Group Dynamics: Theory, Research, and Practice, 24(3), 201-211. http://dx.doi.org/10.1037/gnd0000140
Wiggins, J. S. (1991). Agency and communion as conceptual coordinates for the understanding and measurement of interpersonal behavior. In D. Cicchetti & W. M. Grove (Eds.), Thinking clearly about psychology: Essays in honor of Paul E. Meehl, Vol. 2: Personality and psychopathology (pp. 89–113). Minneapolis, MN: University of Minnesota Press.
For most clients – and clinicians – 2020 was an agonizing year. The twin pandemics of COVID-19 and state-sanctioned, systemic racism provided the backdrop to our clinical work. As we begin 2021, we find ourselves still in the thick of both. This period has brought increased anxiety, depression, and isolation (Salari et al., 2020), and further deepened social inequalities (Clouston et al., 2021). As clinicians with an interpersonal bent, we suggest that the metaconcepts of agency and communion help us understand, and perhaps address, some of the challenges of the moment. First described by Bakan (1966), agency encompasses differentiation, autonomy, and power, whereas communion reflects connection, intimacy, and group cohesion (Dawood et al., 2018; Horowitz et al., 2006; Wiggins, 1991). Our attempts to provide free integrative cognitive behavioral group therapy online during this past summer revealed the unique current clinical and ethical challenges to fundamental needs for agency and communion as well as ways we might help foster them in those we serve.
The pandemic has clearly created challenges to communion. The most striking impact to communion in the therapy room is that most of us no longer use a therapy room. Many of us have pivoted to teletherapy, meeting our clients in boxes on screens instead of couches in offices (Pierce et al., 2021). Telehealth creates opportunity for us to support clients in a deeply destabilizing time, providing a steady presence when most of life is not. But the format produces unique interpersonal difficulties, restricting many of the tools we use to establish alliance and connection. For instance, we now typically see clients only from the shoulders up, prohibiting reading of body movements and the mutual interpersonal regulation that more easily occurs in person. And goodness knows there are technical difficulties, such as a Zoom connection glitching during a particularly intimate disclosure. We sometimes found it hard to discern the interpersonal styles and impacts of group members who walked around their apartments while on camera or turned off their camera (e.g., such behaviors can indicate dominant or cold social acts or merely difficulties with the online format). Genuine communion involves a dyad or group in sync with one another, a union of shared goals and experience. This is not always possible with the partially disembodied nature of telehealth. In the best of cases, it can be hard for clients to shift into “therapy” mode in their home space given the demands of kids, pets, and partners. Like many clinicians, we have conducted teletherapy sessions with clients in cars, sidewalks, or a children’s playhouse, the only quiet spaces they could find.
Teletherapy also raises ethical challenges to agency in this sphere. The therapeutic relationship is built on a consensual expectation of confidentiality out of respect for the agency and autonomy of our clients. Teletherapy complicates that. Though we use HIPAA-compliant teletherapy portals, anything transmitted online is less secure than our closed-door offices. More immediately, many of the interpersonal struggles our clients face concern the people with whom they share living space. This has become more pressing with stay-at-home orders and social distancing. We have clients who live with abusive partners, for example, and LGBTQ clients forced back into non-affirming parental homes. Therapy should provide a lifeline for people in heightened interpersonal stress, but the realities of sharing limited space means fewer safe or private spaces for clients to speak honestly about their concerns. This puts our clients at risk should an unintended audience overhear our sessions. In a group context, there are additional challenges (Weinberg, 2020). When group members participate in their homes and private spaces, clients can’t know who is within earshot of other group-member’s computers, further increasing the risk of unintentional and nonconsentual disclosure.
Despite such clinical challenges, centering on the tension between agency and communion (Bakan, 1966; Horowitz, 2006) helps us appreciate and navigate the background conditions of our clinical work. As the world experiences the COVID-19 pandemic, so too must we face the realities of racism and social injustice. As with the coronavirus, the harms of injustice are not equally distributed. While there is beauty in common experience and realizing that we’re not alone in our struggles, uninvited or inappropriate attempts at agency or communion can generate frustration, anger, or disgust (Hopwood et al., 2011). Attempts to create unwelcome communion or deny people rightful agency can also be a source of ethical harm. This is no different in the therapy room, and we are obligated to think about how to navigate power and agency imbalances in our spaces.
We live in Seattle, and our city held massive protests against racist police brutality—which we viewed as agentic strivings in a communal form—nearly every day of the summer. We ran several transdiagnostic anxiety disorder therapy groups during these months, each group diverse in age, gender, race, sexual orientation, and political leanings. Group members felt differently about the protests, and we were challenged to build group cohesion or “we-ness” (i.e., communion) amidst this social backdrop. Although imperfectly, we strove to maintain a creative tension between agency and communion.
With regard to agency, we noticed twin temptations to discuss political differences as well as to ignore divisive topics to prevent a rupture in the group. Neither of those felt like the right choice. For some members of our group, this was a merely intellectual discussion. To them, Black Lives Matter (BLM) is one possible position among many—something to debate like tax rates. For other members, BLM is a call for the most basic of human rights. There are very different stakes in this game. Genuine communion requires taking on the stakes of others, and that is not always possible in time-limited engagements. Permitting intellectual debate over BLM would involve asking for very different levels of cost and vulnerability from different members, without the consent of the people asked to bear the highest cost. As clinicians, we have ethical obligations not to allow our therapy to reproduce and perpetuate social harms. Honoring group members meant pulling back on communion and pushing forward on agency at times. And so we did, spending time talking about the city’s events with clients individually before coming together as a group. When clients needed to process experiences that put them in marginalized or non-consensually vulnerable positions within the group, we used breakout rooms to facilitate such processing prior to returning to group tasks. Drawing upon the Structural Analysis of Social Behavior (Benjamin, 2011), this strategy could be framed as clinicians granting and clients taking autonomy in place of group dominance versus submission exchanges. Other strategies to empower included modeling and normalizing explicit disclosure of identities and pronouns for those who chose to share. Also, we used in vivo and imaginal exposures targeted to increase agency and self-efficacy. Members high in social anxiety helped run the group and decide on break length. And as each individual practiced during sessions in order to gain mastery over their deepest fears, they were cheered on by the group, a uniquely communal process to support individual agency.
To foster communion in our online groups we adopted strategies such as eliciting disclosures about shared fears. As clinicians, we somewhat exaggerated our nonverbal expressions and gestures to invite active engagement, and monitored the chat function to incorporate chat comments into the larger dialogue. The format of seeing into each others’ living spaces further fostered connection, as we introduced our canine and feline family members to each other. We laughed together at unexpected “Zoom-bombing” by clients’ children. Moreover, as an exposure-based therapy, we incorporated as many shared exposures as we possibly could. In vivo exposures that would normally only be witnessed by the clinican, or done as homework between sessions, now happened in group. When one group member worked on a difficult exposure around wearing unpreferred clothing, other group members spontaneously changed into matching outfits as support. When one member practiced receiving compliments from the group, the group insisted this become a regular event every session, picking a different “love bomb” target each week.
Being mindful of the dance between agency and communion serves us well, even online during difficult times. More importantly, it allows us to better serve our clients.
About the authors:
Tilda Cvrkel is an ethicist (UCLA) currently working on her second doctorate in clinical psychology at Seattle Pacific University.
Thane Erickson is a professor of clinical psychology at Seattle Pacific University
References
Bakan, D. (1966). The duality of human existence: Isolation and communion in Western man. Boston, MA: Beacan Press.
Benjamin, L. S. (2011). Structural analysis of social behavior (SASB). In L.M. Horowitz & S. Strack (Eds.), Handbook of interpersonal psychology: Theory, research, assessment, and therapeutic interventions (pp. 325-342). Hoboken, NJ: John Wiley & Sons.
Clouston, S. A. P., Natale, G., & Link, B. G. (2021). Socioeconomic inequalities in the spread of coronavirus-19 in the United States: A examination of the emergence of social inequalities. Social Science & Medicine, 268, 113554. https://doi.org/10.1016/j.socscimed.2020.113554
Dawood, S., Dowgwillo, E. A., Wu, L. Z., & Pincus, A. L. (2018). Contemporary integrative interpersonal theory of personality. In V. Zeigler-Hill & T. K. Shackelford (Eds.), The SAGE handbook of personality and individual differences: The science of personality and individual differences (p. 171–202). Sage Reference. https://doi.org/10.4135/9781526451163.n8
Hopwood, C. J., Ansell, E. B., Pincus, A. L., Wright, A. G. C., Lukowitsky, M. R., & Roche, M. J. (2011). The Circumplex Structure of Interpersonal Sensitivities. Journal of Personality, 79(4), 707–740. https://doi.org/10.1111/j.1467-6494.2011.00696.x
Horowitz, L. M., Wilson, K. R., Turan, B., Zolotsev, P., Constantino, M. J., & Henderson, L. (2006). How interpersonal motives clarify the meaning of interpersonal behavior: A revised circumplex model. Personality and Social Psychology Review, 10(1), 67–86. https://doi.org/10.1207/s15327957pspr1001_4
Pierce, B. S., Perrin, P. B., Tyler, C. M., McKee, G. B., & Watson, J. D. (2021). The COVID-19 telepsychology revolution: A national study of pandemic-based changes in U.S. mental health care delivery. American Psychologist, 76(1), 14-25. http://dx.doi.org.ezproxy.spu.edu/10.1037/amp0000722
Salari, N., Hosseinian-Far, A., Jalali, R., Vaisi-Raygani, A., Rasoulpoor, S., Mohammadi, M.,
Rasoulpoor, S., & Khaledi-Paveh, B. (2020). Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: A systematic review and meta-analysis. Globalization and Health, 16(1), 57. https://doi.org/10.1186/s12992-020-00589-w
Weinberg, H. (2020). Online group psychotherapy: Challenges and possibilities during COVID-19—A practice review. Group Dynamics: Theory, Research, and Practice, 24(3), 201-211. http://dx.doi.org/10.1037/gnd0000140
Wiggins, J. S. (1991). Agency and communion as conceptual coordinates for the understanding and measurement of interpersonal behavior. In D. Cicchetti & W. M. Grove (Eds.), Thinking clearly about psychology: Essays in honor of Paul E. Meehl, Vol. 2: Personality and psychopathology (pp. 89–113). Minneapolis, MN: University of Minnesota Press.