This article explores the potential for a shifting lens in psychiatric treatment following the collective experience of social isolation as a pro-social action. The use of masks and isolation are examined from a drama therapeutic perspective in order to find processing and catharsis in the time of the global pandemic, COVID-19.
“I am stockpiling antibiotics for the apocalypse, even as I await the blossoming of paperwhites on the windowsill in the kitchen.” (Lamott 2018, p. 1)
The global community is currently enduring collective uncertainty, isolation, grief and trauma as we experience the COVID-19 pandemic. The way governments, doctors, epidemiologists, and infectious disease experts have encouraged the population to protect itself is through isolation. Staying home, good hand hygiene, wearing a mask, reducing and limiting interactions in public are all being named the vector for which the virus will be extinguished (World Health Organization, no date). Adhering to these guidelines creates solidarity, a sensation of being a patriot of public health and being the good and responsible citizen. By choosing to self- and socially-isolate a person is exhibiting socially positive behaviour. This article will explore the therapeutic role of masks and isolation practices during COVID-19 and the potential power of re-framing applications in clinical work with clients.
Minerson, M. 2020, On Feeling Essential 1. Photograph of mixed media mask. Fort Smith, Northwest Territories: Private Collection.
As a drama therapist in practice during this time of social and physical distancing and isolation, I have been pondering the heightened awareness of masks and our use of masks to act as an agonist for isolation. I have reviewed the masks I have been wearing this time - literally and metaphorically. As a clinician who practices both in a hospital facility and now, practicing telepsychology from home, the literal masks I wear include basic surgical masks, N95 masks (respirator-style masks for airborne precautions; Public Health Agency of Canada 2017), and a feathered and sequined play mask. Masks of metaphorical protection that I am wearing include the blue-screen glasses I wear to do telepsychology which are not a mask I wear when I am working in my office, the background I have chosen to show off my home, and not wearing make-up while digitally practicing. Both styles of masks offer me the ability to move within drama therapeutic overdistance (extreme rationality) and underdistance (overwhelming emotion), titrating the level of comfort I have with my new aesthetic distance in this time of the novel and evolving normal (Landy 1997).
These masks I wear are both inner and outer expressions of my current willingness to risk exposure and also to self-isolate for my own and the greater good.
When I wear a medical mask to attend to a client at the hospital in which I work, the version of the therapist they encounter is one who is masked; not only am I isolating the potential virus droplets, but I am also isolating parts of my embodied tool of self with which to create connection, rapport and provide comfort. There is always a power dynamic between therapist and client that the drama therapist works to disrupt, explore and play with (Mayor 2010; Sajnani 2009). However, the specific power dynamic which is at play when I enter a room in full Personal Protective Equipment (PPE) is startling. In this PPE, I provide mental health support for my client who is drastically under-protected; perhaps wearing a medical mask, but often with only their personal masks, literal and metaphoric. As clinicians, during these in-patient encounters as well as the online sessions we are engaging in right now, we remain in the empowered position and able to label what is adaptive or maladaptive in our patients. As a global community, we have decided that the adaptive behaviour is to isolate. Under the layer of gown, gloves, goggles and mask, I am steeped in “the depths of the responsibility I have towards him or her - and [my PPE] makes that responsibility, almost overwhelmingly, infinite” (Thompson 2009, p.163).
Minerson, M. 2020, On Feeling Essential 2. Photograph of mixed media mask. Fort Smith, Northwest Territories: Private Collection.
Often on psychiatric units, isolation is used as a form of control and management for unsafe behaviours exhibited by patients to assert a perception of safety that keeps that patient, staff and other patients in the milieu from harm (Tunde-Ayinmode and Little, 2004 p. 347). In the current climate of COVID-19, there is a global re-framing of the concept of isolation to be something positive that all citizens in all nations are doing.
Clients that come to psychiatric units from situations where they are living with fear, instability and lack of safety often exhibit a tendency to self-isolate in their rooms, refusing to shower or change their clothes for a time. Traditionally in the in-patient setting, clinicians label this as non-compliant. Now that most clinicians have experienced personal isolation with positive benefit through this pandemic of COVID-19, could this collective experience of trauma and isolation provide for greater understanding of felt empathy and the sensation of power that isolation can bring? If so, how might this benefit rapport, stabilization, maintenance and treatment?
Can therapists working in these settings further utilize a trauma-informed lens and attempt to see the strength that is being performed versus the negative behaviour? Remaining alone and malodorous is a form of protection - it keeps people away and leaves the patient in isolation. Medically, utilizing PPE is described as applying isolation precautions. Layers of patient autonomy are lost when a patient is admitted to a psychiatric facility and it can be difficult to trust a new location with a new community. As perhaps harm had previously occurred in a hospital setting, the client is likewise utilizing isolation precautions. As Larue et al. (2013) note, some patients found that being in isolation brought a “feeling [of being] protected from the outside world; patients also reported that seclusion allowed them to avoid actions they might regret; and gave them space to collect, re-energize, and restore themselves” (p. 321). Encouraging acts that increase autonomy, such as titrating exposure to the general unit population, is akin to when a member of a community is recovering from COVID-19. They are slowly re-entering their neighbourhood, workplace and community connections, which were the locations of the harm, or contracting the virus.
True trauma-informed work is when clinicians hold space for the process of trust to naturally construct, thus allowing the patient to inform clinical staff when they are ready to begin to engage and heal. This trust creates a therapeutic milieu that is now safe enough to remove the mask of protection.
Is it possible then to redefine the action from a psychiatric behaviour, to an act of self-preservation or an ask of connection? And perhaps in this context, we can widen our definition of compliance to include one where the patient knows that being alone in seclusion or isolated from the general population of the unit will lead to a calming and soothing outcome. Are our psychiatric patients more aware of what they need than we credit them, and might they be asking for what they need in the only way they know how? How do we honour the patients who have literally requested isolation because they know that they need to be away from others? Could we see this as an opportunity to do better coming out of this pandemic? As Noda et al. (2012) highlight, might we be able to learn more from our patients when we engage in “such elements of treatment as respect for patient dignity and empowerment in shared decision making – even if the overall treatment includes coercive measures” (p. 402) such as isolation.
Just as we have had to honour our own needs for isolation during this time, believing our clients when they isolate, or request isolation might be a way to honour dignity and empowerment in the clinical space.
Minerson, M. 2020, On Feeling Essential 3. Photograph of mixed media mask. Fort Smith, Northwest Territories: Private Collection.
In an attempt to process layers of my current work with my clients, my own coping and sensations as a drama therapist at this time, and my connections with my community around the world who are experiencing varying levels of fear, loss, grief, panic and (dis)connection, I constructed a mask as a projective. The experience of the construction of the piece was embodied and considered as a fully sensory experience. The sense of touch and sight engaged in creation, aromatherapy being diffused engaged the olfactory, hot herbal tea was a comfort in warmth and taste, and music was played nearby, providing auditory stimulus. Engaging all senses in the creation was a frame structured intentionally, as my entire body and all senses have been affected by the pandemic, and “this framing aspect of the mask invites [me] to get hold of the problem and provides enough time for the energy of its message to flow so that [I] might understand the problem differently” (Keats 2003, p. 110). The mask is mixed media in composition, utilizing a prefabricated base, an N95 mask, the mask package wrapping, a ping pong ball, modelling clay, eyeglasses, paint, tissue paper, paper, a finger puppet, pipe cleaner and magazine collage. While creating this piece, I had moments of joy, pleasure, and release, as well as moments where I felt overwhelmed, as if the task were too much, and the music became overstimulating. As the mask began to take form and came into being, I was struck by the accuracy of my experience and what Landy (1996) stated:
My mask reflected the entirety of my own complex experience, and the experiences I am holding for others. Completing the work felt satisfying, like a release, and as Keats (2003) reminds us, “as an artistic act, the making of the mask is healing in itself” (p. 114). The produced mask accurately embodies my many sensations as a therapist, artist, friend, family member, colleague, and countless other roles.
Minerson, M. 2020, On Feeling Essential 4. Photograph of mixed media mask. Fort Smith, Northwest Territories: Private Collection.
Perhaps this pandemic blanket of uncertainty we are all experiencing to varying degrees right now accurately mirrors the feelings our clients have when they encounter us. Is there space, empathy, and a willingness for us, as therapists to acknowledge our current sensation of vulnerability and then to allow it to change the masks and varying degrees of isolation we use in daily practice?
Can the mask we wear as professional/ clinician/ helper be removed so that we can sit in empathy with those who have always felt and tried to show us that sometimes isolating on an in-patient unit is the best way to keep everyone safe?
As we continue to experience social distancing, isolation and the many masks we apply each day to protect our fellow humans from virus contraction, I offer that this collective experience of COVID-19 can positively impact our practice as clinicians, remembering that this is the same social and physical distancing that our clients require when they meet us. Recognizing this, and allowing it to affect our practice, is an act of compassion and “I have never witnessed both more global and national brutality and such goodness in the world’s response to her own” (Lamott 2018, p.4) as I have during this pandemic.
Keats, P. A. (2003) ‘Constructing masks of the self in therapy’, Constructivism in the Human Sciences, 8(1), 105-123.
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Larue, C., Dumais, A., Boyer, R, Goulet, M., Bonin, J., Baba, N. (2013) ‘The experience of seclusions and restraint in psychiatric settings: Perspectives of patients’, Issues in Mental Health Nursing, 34(5), 317-324, available: doi: 10.3109/01612840.2012.753558
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Mallory Minerson (MA, RDT, CCC, CDWF-Candidate, LPN) is a registered drama therapist, trained at NYU and currently the Government Affairs Chair for the North American Drama Therapy Association. She is also a certified Canadian counsellor, certified Daring Way™ facilitator - candidate and licensed practical nurse. Ms Minerson currently practices drama therapy and psychotherapy in Canada’s Northwest Territories, where her practice is focused on trauma, shame, and shame resilience.