Going to therapy while the world is on fire
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A car ablaze in Sweida, Syria, following clashes between Bedouin and Druze factions on July 14.
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One of my patients doesn't wait for me to ask how he is doing as we start an early morning session. 'I can't do therapy today,' he says. I listen, curious. 'There's just too much dissonance. Not sure I can really go into the details of what's happening in my life when the world seems to be crumbling all around.' I've heard many versions of this expressed in therapy over the past several months, a hesitation about feeling entitled to a 50-minute therapy session. (I received consent from my patients to reference their stories anonymously.)
'Your life matters,' I say. 'Yes, big things are happening, but this doesn't mean your life doesn't have significance.' My words feel flimsy, perhaps because I'm only partially convinced of them myself. My patient knocks them down in the next three seconds. 'Yeah, well, you're a therapist, so of course you are going to say that.'
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Sometimes I need a good little kick of radical honesty in a session to sharpen my focus. 'Many people are talking about this very question in therapy,' I say. I tell him that I'm thinking about this question, too.
He tells me about hypernormalization, a term introduced by the Russian-born American anthropologist Alexei Yurchak to describe the way in which people carried on with life pretending everything was normal in the 1970s Soviet Union despite the systemic failure of government and institutions. I listen in silent agreement.
My patient tells me he is grateful for having just gotten a good job offer, but his happiness is tempered by his awareness of what is happening in the country and the world. Some of his friends want to leave the country. 'What do I do?' he asks. 'Should I escape to Europe? Focus on my job? Amass wealth and buy a house? Fight? How do I fight?'
A Ukrainian firefighter worked to extinguish a fire following Russian drone strikes on houses in Odesa, on July 11.
OLEKSANDR GIMANOV/AFP via Getty Images
We end the session without having gotten into the dynamics of the romantic relationship he had wanted to talk about.
I remember learning in grad school about the late American psychologist Urie Bronfenbrenner's biopsychosocial model, which holds that human development is influenced by multiple interconnected systems in a person's environment. An illustration showing a stick-figure individual at the center of several concentric circles: family and close friends first, with community and school one ring out, and politics, government, religion, and culture circling the whole. I imagine the stick figure — my patient or me — becoming uncentered, floating across the lines that are themselves wobbly.
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Therapy feels like this: destabilized.
Can we truly shut out the outside world and carry on with day-to-day therapy work when the world keeps smashing into us? What weight do our individual lives carry? Some patients wonder at the self-indulgence of paying good money to talk about relationships, health, families, careers, kids, pets. These perennial questions for the practice of therapy have resurfaced with a new urgency over the past several months.
For other patients, the political world has become of immediate relevance to their day-to-day lives. Depression, anxiety, anger, dissociation, and fear are heightened for many. Scientist and doctor patients whose research funding has been cut question their life's direction. Other patients talk about deportation; yet others are fearful of losing food stamps and housing benefits. A woman with a severe trauma history, whose government-subsidized housing has provided her with a sense of safety she had never felt, tells me she has a suicide plan if her benefits get taken away. She is not joking. A colleague mentions a patient with a history of delusions who is terrified when he sees black SUVs pull up in front of his building. The presence of Immigration and Customs Enforcement in his neighborhood now gives his delusions a grounding in reality. The line that separates anxiety from paranoia has shifted.
Smoke and fire rose to the sky following an Israeli army bombardment in the northern Gaza Strip, as seen from southern Israel on July 10.
Leo Correa/Associated Press
And then there are many patients who, like me, feel enraged and powerless, consumed and wanting to escape.
Meanwhile, life on the street in my neighborhood looks eerily normal: People get coffee, kids play while parents chat at the playground, runners run, and, of course, people go to their weekly therapy appointments.
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I ask my own therapist, 'Is it strange for me to talk to you about my own little life in the context of the world? What are you telling your patients? What should I be telling mine?' I see in her eyes that she knows what I'm talking about. She is asking similar questions. She tells me about a book she is reading about the power of defiance. Sounds good, I tell her, as I put it in my online cart. Not a typical therapist move. We are out of mainstream therapy water.
Both as therapist and patient, I wonder how much my individual story has weight and consequence in the context of a breaking social order. Is there a risk that I am becoming complicit with this break if I carry on talking about relationships and family and summer plans in my therapy as if nothing else were going on? And what if I don't feel like talking about politics in therapy? Or what if I need to shut out the world so I can focus on what's happening in my smaller sphere?
I reflect on what I had said to my patient, about his life continuing to matter. It hits me on my bike ride home along the river after my therapy appointment, alongside the people sitting by the water taking in the afternoon sun.
Our lives matter. The fact of an administration that seeks to crush individual voices, and in particular dissenting ones, urges us to stay aware of ourselves. Many skills developed in therapy are important not just to individual well-being and personal growth; they are tools to support coping and, if we want them to be, can be vehicles for political change and resistance. These tools and vehicles include self-exploration, curiosity, reflection, questioning of previously held assumptions and what we thought were given truths, taking risks, tolerating distress, managing uncomfortable emotional states, appreciating one's unique identity, questioning fear, building on one's strengths, and exploring possibilities for change. At a time when difference and diversity in being and critical thought are in peril, now more than ever is the time to bolster those very qualities.
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"The very real threat to the physician-patient relationship that is accelerating today is from legislative intrusions into the patient room. When laws are passed that make even just exploring options with patients around things like reproductive health a criminal offense, government has overstepped. "When laws are enacted that require a physician to call their lawyer rather than a specialty consult before providing life-saving care, we have entered a new and dangerous era of governmental oversight. Recent laws have done more damage to the sanctity of the physician-patient relationship that Medicare actually helped improve." Rep. Durward Gorham Hall, 1969 Representative Durward Gorham Hall, MD (R, Missouri), made these remarks below during debates on Medicare in the House of Representatives: "This conflict is testing whether art and science of medicine will be permitted to grow and flourish in freedom and competitively, or whether progress in medicine will be stunted and shriveled by an excess of Government control." Commentary Jonathan B. Jaffery, MD, MS, MMM, chief healthcare officer at the Association of American Medical Colleges: "By supporting the training of physicians, Medicare helps create the physician workforce for future generations of Americans, crucial for the care of an aging population. And through iterative developments over the last 60 years, such as Coverage with Evidence Development or the Center for Medicare and Medicaid Innovations, the Medicare program — coupled with federal investments in biomedical research — has been able to support innovations in both medical technologies and models of care delivery that continue to improve the lives and well-beings of millions. Jonathan B. Jaffery, MD "The reality is, prior to 1965, many elderly Americans with healthcare needs were forced to rely on financial support from their families or spend all their life's savings, hope for charity care, or forego care altogether. And of course, the cost of care has only skyrocketed, so that in 2025 even very high-net worth individuals would struggle to cover the costs of a lengthy hospitalization or extended illness, let alone the price tag of many new life-saving medications." 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William Hoagland "Today, Medicare Advantage, dominated by 'third-party' corporate insurance companies, has transferred the physician's independent decisions to actuaries and corporate financial decision makers. The result has also been horizontal consolidation of what were locally controlled entities to nationally or regionally controlled corporations along with vertical consolidation of payers and care delivery entities. "The impact of these changes, along with dramatic scientific advances in diagnosis with advanced treatment protocols, precipitating higher healthcare utilization, has not been to reduce costs but to in fact increase healthcare costs." President Lyndon Johnson ( left ) flips through the pages of the Medicare bill so former President Harry Truman ( right) can see it. Following passage of the Social Security Amendments of 1965 out of the Senate by a vote of 68-21, President Lyndon B. Johnson said: "It will help pay for care in hospitals. If hospitalization is unnecessary, it will help pay for care in nursing homes or in the home. And wherever illness is treated — in home or hospital — it will also help meet the fees of doctors and the costs of drugs." Commentary Bruce Leff, MD, professor of medicine and director of the Center for Transformative Geriatric Research, Johns Hopkins University School of Medicine in Baltimore: "Johnson's statement regarding care at home was appropriate for the mid-1960s. To this day, skilled home healthcare remains the most used home-based service by Medicare beneficiaries. "Since Medicare was enacted, a bevy of evidence-based home care delivery models have been developed and proven. These home-based models span the care continuum including home and community-based services, home-based primary care, transitional care, and home-based palliative care. Bruce Leff, MD "Unfortunately, Medicare payment policies incentivized the centralization of care in facilities and a facility-centric culture of care delivery. Care delivery hasn't kept pace with the needs of an aging population with a high prevalence of homebound older Americans or with the advances that enable even hospital care to be delivered to patients in their preferred setting, their homes. "The hospital of the future will comprise of emergency departments, operating rooms, and intensive care units. Most other care can and will be provided in the home setting. We have all the pieces to develop this future home-based care vision. Achieving this vision will require a culture shift with associated payment and regulatory enhancements, ongoing attention to improvements in technology, logistics, and data management." An elderly woman shows her gratitude to President Lyndon B. Johnson for his signing of the Medicare healthcare bill in April 1965. Johnson continued: "Older citizens will no longer have to fear that illness will wipe out their savings, eat up their income, and destroy lifelong hope of dignity and independence. For every family with older members, it will mean relief from the often-crushing responsibilities of care." Commentary Gretchen Jacobson, PhD, vice president, Medicare program, Commonwealth Fund: Gretchen Jacobson, PhD "One third of Medicare beneficiaries said in 2023 that it was difficult to afford healthcare costs. More than 1 in 5 beneficiaries reported in 2023 delaying or skipping needed healthcare because of the cost. Similarly, some Medicare beneficiaries trade off paying for other necessities to pay for needed healthcare. The lack of a limit on out-of-pocket spending on hospital and physician services for traditional Medicare has, for most traditional Medicare enrollees, necessitated purchasing supplemental insurance coverage. Yet, the limited availability of this supplemental coverage has resulted in more beneficiaries enrolling in Medicare Advantage and high underinsurance rates among those in traditional Medicare without supplemental coverage. "Medicare beneficiaries who do not have a family caregiver and cannot afford to pay out-of-pocket for a formal caregiver are typically forced to deplete their financial resources to qualify for Medicaid coverage, the largest payer for long-term care in the US."
