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When No One’s The Expert: A Preliminary Study of Social Workers’ Perspectives on Shared Loss in Counseling During COVID-19

In this preliminary study, social workers’ experiences of adjustment and loss during the coronavirus disease (COVID-19) pandemic were explored as they, along with their clients, coped with the resulting emotional and psychological impacts. As death and illness rates increased alarmingly, masters-level social work students’ discourses and feedback in a course on grief and loss revealed a knowledge gap surrounding counseling in face of shared loss that led to a pilot study. Subsequently, a qualitative research study (n = 7) of video self-reports from clinical social workers was conducted to further explore their losses and their consequent professional impact. They responded to the question, “What losses have you felt in this pandemic that have impacted you professionally?” Participants listed multiple losses related to work (e.g., loss of professional therapeutic space, loss of the work/life divide) and recognized the challenges to maintaining a personal sense of well-being. In consideration of the pandemic’s impact when counseling others, participants identified the following themes: greater emphasis on one’s own well-being, greater focus on maintaining strong therapeutic rapport, the value of creativity in the new therapeutic space, and a continual assessment of dynamic shifts. For society to process—which means, largely, to grieve—the losses related to COVID-19 and adjust to the world as is, there is a need for counselors to do so as well. This paper explains how some counselors have experienced loss through their work and coped with it; thus, they have been able to support their clients through the pandemic.


Introduction
This study originated from concerns expressed by social work students in a grief theory and practice course about supporting clients during the COVID-19 pandemic. When this class was held in New York City (NYC) in April 2020, the number of new COVID-19 cases there had reached over 6,000 per day (NYC Health, 2020). Students expressed sadness, concern, and fear for themselves, their loved ones, and their clients in the face of anticipated and experienced losses and adjustments. A sense of uncertainty was pervasive; students voiced their anxieties about the spread of the disease and the quarantine's length. They also questioned how to work clinically at that time and throughout the pandemic. Given that the course's main objective was to 'increase confidence and decrease concern when working with clients who were experiencing loss,' some students expected that it would navigate them through loss experiences, both personal and client-based, during the pandemic.
At the time, the literature on COVID-19 was silent on the topic of shared loss-loss(es) experienced as a result of a shared experience-and its impact on the therapist-client relationship. Studies regarding mental health and COVID-19 at this point primarily focused on patient anxiety related to the transmission of COVID-19, depression, post-traumatic stress, and the overall psychological changes resulting from quarantine (e.g., Centers for Disease Control & Prevention, 2020; Liu et al., 2020;Peng et al., 2020;University of California San Francisco, 2020). Depression and anxiety among health care workers were also noted in early studies (Lu et al., 2020). The psychological impact of related deaths was addressed in a cursory fashion through the correlation between symptoms of post-traumatic stress disorder (PTSD) and earlier pandemics, such as SARS in 2004 (Hawryluck et al., 2004). However, the unique characteristics of the COVID-19 pandemic and its psychological effects on clinical social workers, clients, and clinicians, as clinical social workers started to experience losses in security (income, housing, food stability, etc.) and the physical well-being of social workers and their loved ones was yet to be explored in pandemic literature.
Loss experiences apparently presented clinical social workers with particular challenges that were not captured through popular grief theories. Before this pandemic, these theories were critiqued for their applicability to real-life experiences and their focus on certain kinds of individual experiences. Friedman and James (2008) argued that popular grief processing theories, such as those by Kübler-Ross (1969) and Worden (2009), have universalist notions of normative stages and processes in grief, which are ill-fitted to individuals' real-life experiences. Stroebe and Schut (1999) critiqued contemporary grief theories for their skewed purview, which relied too heavily on Western women's experiences in coping with the death of a loved one (Williams, 2014). These researchers offered a broader delineation of grief that does not prescribe resolute feelings, states, or tasks for healthy processing. Given the multitudinous losses during the pandemic, it seems both advisable and necessary to consider broader approaches to grief to comprehend the particular emotional and psychological challenges that exist from grieving intensely while surrounded by others who are doing the same.
Shared trauma was the theoretical framework useful for the examination of therapists' loss experiences during this pandemic. Shared trauma literature locates the loss reactions of therapists and their clients on a spectrum of difficult shared experiences-from "traumatogenic environments" (Tosone et al., 2012, p. 231), such as September 11th, to the serious illness or impending death of a therapist (Heilbrunn, 2019). These shared experiences lead to parallel mourning processes, wherein the therapist and client simultaneously experience grief (Tosone et al., 2003). Therapists who experience shared trauma face a twofold challenge that complicates their mourning: they face personal experiences of losing while facilitating their clients' processing of identical or similar ones. According to shared trauma theorists, there are positive consequences to shared trauma for "resilient" (Boulanger, 2013, p. 43) therapists. Such therapists emerge from grief processing as the bereaved who accept and adapt to loss. They emerge with an enhanced sense of meaning, shifted or broadened perspective, and strengthened insight and empathy (Tosone et al., 2012).
The term 'shared loss' is also theoretically applicable to therapists' loss experiences today. It emphasizes the loss experience and separates the phenomenon delineated from the strictest definition of trauma (i.e., a significantly threatening event or series of events for the person who experienced it). In other words, the phenomenon is seen as difficult, but not traumatic. Christiaanse and Haartsen (2020) offered an example of usage of this term in their portrayal of community-wide losses as a community's "shared sense of loss" (p. 1). Their research focused on the loss of a familiar workplace, the attachment of community members to their shared place, and the psychological effect of a break from it (Christiaanse & Haartsen, 2020). References to shared loss for difficult, though not traumatic, occurrences and the association between place-related loss and shared loss were considered in this study because the term identifies difficult, nontraumatic experiences and place change.
Nearly a year after students completed the aforementioned course, many significant losses have resulted from the pandemic. Unemployment has been at the highest level since the Great Depression (Petrosky-Nadeau & Valletta, 2020). Further, housing insecurity and homelessness are increasing as households that might have incurred serious cost burdens pre-COVID struggle to retain housing and cover other basic expenses (National Lawyers Guild, 2020). Additionally, atrisk groups for life-threatening contraction of COVID-19 are either losing their social connections because of quarantine or risking the loss of health by interacting with others. The recognition that helpers now need help extends beyond research and academia to NYC streets, where the ritual of shouts, applause, and pot clanging at 7 p.m. is a citywide, daily occurrence. The literature also extends to a discussion of other supportive care professionals. Rabow and Bullard (2020) discussed the increased risk of secondary trauma as professionals support clients through COVID-related traumatic losses. While it is reasonable to assume that therapists have suffered losses-and found it difficult to counsel through them-these issues are addressed in a cursory fashion at best within extant literature.
This study emerged from an interest in the mental health of clinical social workers and that of their clients, understanding that the two intersect in transference-countertransference as they navigate shared experiences.

Method
Each study participant was asked to provide a brief selfrecorded video response (5-10 min) to a two-question survey. The study was approved by the university's Institutional Review Board (IRB). A snowball sample (n = 7) was collected through email outreach to clinical social workers. The response rate to the invitation was approximately 35%. Each participant was expected to be a licensed clinical social worker (LCSW); additionally, they were to be counseling individuals in New York (NY) through the pandemic. Exclusion criteria were either no licensing or licensing as a licensed master social worker (LMSW) only, employment outside of NY, and a social work position that did not involve counseling work. The age range of participants was 30-45 years; the average applicable experience was 10 years.
In June 2020, an invitation was sent to prospective participants who were directly known to researchers and their network of professionals via LinkedIn. Those who indicated interest were subsequently issued a consent form, which outlined possible risks, benefits, and survey questions. Survey questions were delivered via email, along with instructions on how to submit the video to researchers. The questions were as follows: (1) What losses have you felt in the face of this pandemic and how have they impacted you professionally? Please do not include death or dying in your response.
(2) How have you adjusted to these in your work life?
The video responses and consent forms were stored in a password-protected file. Responses were de-identified in the inductive coding process. The two researchers who coded the responses thematized the spoken (not visual) data.
The frequency of identified losses and changes in therapy was also noted in each participant's response. A doctor of social work (DSW) and a practicing social worker, both of whom counsel in NY, coded the results and agreed on the themes to be included in the study's results.

Multiple Losses
While reflecting on loss in their counseling work, participants often mentioned the loss of therapeutic space, its impact, and accompanying losses. One participant described how established clients lost both a co-created "safe" space and a "ritual" of preparing for and being in a space that was separate from everyday life. Another focused on the loss of the ability to "read the emotion in the room." One participant shared that the loss of the in-person work environment meant losing contact with fellow professionals: "Passing colleagues in the hall was important. And working in a place that's different from my home, having that separation from my personal life…without that, that's hard." The loss of time and structure was another consequence of working from home: "Initially, time passed really slowly and not really knowing what you did with your day, or it went by quickly… boom, the day was over!" This person noted how the loss of time and structure correlated with changes in the ability to focus. On days in which time passed slowly, a loss of focus was also felt.
The loss of professional space caused other related losses. It sometimes had a disorienting effect on professional identity and workday practices. One participant described a new blurriness between the professional and personal selves: "There are blurred lines between my personal life and work self…I work from my bedroom." Another noted that working from home was disorienting and created an out-of-control feeling throughout the workday: "There were so many things that were out of my control. I didn't know what day or time it was." Some participants lost business as well as childcare and other support that allowed them to work full-time. One said, "I have lost some clients for financial reasons and experienced loss in my own finances as a result…now, I feel [the] responsibility to watch our kids and help with their schooling." Losses were faced professionally while new responsibilities were added. One participant's therapeutic workload decreased but "work" had increased overall due to home and family commitments, a situation that was described by several other participants.
While all participants acknowledged that they experienced many work-related losses, none saw them as completely negative. One participant noted, "I've felt many forms of loss," while also describing a mix of positive and negative consequences and feelings. The sentiment was felt by all participants. Multiple losses did not result in overwhelming, purely negative feelings from any participant. Rather, an attitude of acceptance-one that "makes the best of" work changes-was commonly conveyed. One participant's delineation of the work-from-home scenario is illustrative: "I've had the privilege to work from home and I have a two-year-old daughter at home. Having a call with colleagues while my daughter is going down for a nap screaming…it's [been] interesting and a huge adjustment, to say the least."

Greater Emphasis on One's Own Well-Being
All participants recognized new and difficult feelings and states. One participant linked "facing my own anxiety" with the loss of a familiar work environment and work routine, as well as the loss of health security with the looming risk of COVID-19. Another felt increased fatigue while managing more responsibilities at home and working with clients who were struggling with their own losses as a result of this pandemic. One participant expressed feeling the loss of valued self-care routines: "I've lost the ability to go outside my home and create a separate space." Aware of these new feelings, participants implemented activities to maintain and enhance their well-being. Several said that they increased their time outside the home and/ or cultivated mind-body practices, such as meditation and exercise. Some mentioned reaching out more to people in their personal and professional lives. Many used multiple self-care techniques that they described as new routines to address their losses. One participant who felt a lack of consistency reestablished it by waking up, starting, and finishing work at the same time every day. This person also worked to counteract the lack of self-focus, which colleagues recognized, by "checking in" with "colleagues, supervisors, and supervisees." Rather than taking on new self-care exercises, some participants espoused self-compassion. One participant, who had contracted COVID-19, said, "I'm cutting myself some slack, as I was pretty ill." Another participant acknowledged that the threat of illness had triggered more attention on physical well-being" and the determination to "pace myself work-wise." Not watching the news was another strategy portrayed as self-care by one participant because watching it and facing the impact of illness clinically was "overwhelming." All participants linked new or enhanced self-care and self-focus to the losses felt. One participant showed a connection between the two in the self-report. Following a statement that acknowledged this sense of loss ("it affects how I feel about my work as well….so we're all adjusting"), this participant moved on to describe "restorative" practices (e.g., walking outside between sessions and speaking to work colleagues regularly) implemented during quarantine.

Creativity in the New Therapeutic Space
Most participants said that they tried to compensate for the loss of the in-person therapeutic environment. One stated, "I think some of my clients feel the loss of [the] in-person experience. I do too, and I try to recreate that same sense through different means. I might engage in small talk at the beginning of a session, for instance. I try to create a sense of familiarity…to orient us to one another." Several others indicated that they engaged in divergent thinking about therapeutic sessions, which was necessary because of the virtual space where these sessions were now conducted. One participant, who had little guidance on how to serve her clients from home, created a method for contacting clients (e.g., choosing how to contact clients online and deciding which online platform to use) and working with colleagues. Another participant alluded to divergent thinking when discussing the need to "work with (the) differences in dynamics" caused by counseling remotely.

Continual Assessment of Dynamic Shifts
The pressure to be at one's best therapeutically was expressed by the majority of the participants. One stated, "I worry that some of my clients might feel that the work that we're doing together is not at the same depth and caliber. I find myself checking in about my level of engagement throughout sessions, more than I used to before." Like this participant, most of the others indicated that they were assessing client discord related to the adjustment to remote counseling.
Although all participants scanned for therapeutic shifts, none directly discussed whether the quality of therapeutic interactions had decreased. Instead, several participants commented on shifts in therapeutic momentum and maintaining rapport. One participant discussed the loss of a therapeutic "frame" that "holds" (an aspect of rapport) and "implies" (presumably, therapeutic messages that facilitate momentum) and explored how to adjust accordingly. Another participant alluded to changes in therapy by expressing uncertainty about how to provide adequate attention and a "felt presence" to clients remotely.

Relationship Between Loss and Change in Therapy
In terms of the relationship between themes, a parallel between the number of losses listed and the number of references made to potential and realized changes to therapeutic work was noted. Participants who identified the most losses tended to discuss changes in the components of therapy, such as therapeutic dynamics and a changed approach to working more (even if that new approach was giving oneself more, not less, "slack"). This finding was reached through a frequency count between the number of losses listed and the changes noted for each participant. It suggests that participants who felt impacted most by pandemic losses were most likely to view therapy during the pandemic as having changed or needing adjustment.
One participant suggested that client functionality was another complicating factor in the therapeutic course in the face of loss and change. This person rated the transition to remote counseling as less impactful to clients in private practice than the transition to in-person counseling with protective gear and physical distancing for clients residing in an assisted living facilities. This participant believed that these differences could be explained by clients' levels of functioning, as private practice clients generally appeared higher functioning.

Openness to Change
Participants who referenced the relational and ritualistic values of in-person therapy did not mention the potential value of changed attitudes and strategies. Some participants used words, phrases, and depictions that suggested the specialness of the in-person environment (e.g., "ritual," "holding," and/or portrayals of the preparation for in-person therapy and its separateness from ordinary life). Each participant also described the changes they faced in providing remote therapy as challenging or necessary.
Participants who did not focus on the specialness of the former therapeutic environment alluded to the inherent opportunities in remote counseling. This correlation demonstrates a link between therapeutic orientation and style and openness to changes in therapy resulting from the pandemic. One participant did not reference the therapeutic relationship or specialness of the shared therapeutic space, noting instead, the benefits of technology for facilitating online sessions and homework. For this participant, good communication and psychoeducation appeared all-important in therapy and could be maintained virtually: "We have pretty good communication. All psychoeducational material is available virtually…Technology made the impact a little less dramatic." As a result of this therapeutic purview, this participant saw technology as facilitating comparable (not less than) therapeutic interactions.
This correlation demonstrates a link between the therapeutic orientation, style, and openness and remote counseling as a potentially effective forum for therapeutic growth.

Limitations
The study's sample size was determined by the saturation of most of the themes. The reflections and experiences shared in this study are not assumed to be accurate accounts of counseling interactions or representative of the views and experiences of other clinical social workers who have counseled during COVID-19. It is possible that the participants had counseling specialties and related experiences that were exceptional compared to those of all clinical social workers who work as counselors. The views expressed in this study are also not static and may expand and change in subsequent phases of COVID-19.
This research was conducted primarily to provide a snapshot of some clinical social workers' reflections on counseling at a critical time for emotional, physical, and health. This is a preliminary study intended as a first step in examining the phenomenon of counseling with respect to largescale, shared loss.

Discussion
While the shared trauma literature highlights the loss experiences of therapists and their effect on professionals and therapy, the shared loss framework more closely fits the types of losses and difficulties described by this study's participants. Participants focused on losses of a non-traumatic nature. They spoke of coping with place change, from the shared therapeutic space and in-person encounters to the remote therapeutic space. The attention given to therapeutic space by participants is compatible with research and theory on the physical environment and its impact on therapy that argues that therapeutic space can influence perceptions of the therapist's competence, client approval, disclosure, and ease (Pressly & Heesacker, 2001). These findings are also consistent with recent research on therapists' concerns about the transition to tele-psychotherapy during the pandemic (e.g., Kashyap et al., 2020). Although a change that signals significant adjustment, the predominant loss (of physical proximity with clients) described in this study does not compare in degree to the emotional and professional impact described in the literature on shared traumas (e.g., 9/11, "the troubles" of Ireland).
The shared trauma frame might have been more fitting in terms of health-related losses raised by participants. There was silence on the loss of a sense of health-related security (i.e., no statements were made to the effect, "I lost the confidence that I am and will be healthy"). Only one participant mentioned illness, possibly because only one participant had contracted COVID-19. Surveyed later in the pandemic journey, our participants might have had more experiences of threatened health and loss. The original silence could have also resulted from the fact that other participants interpreted the survey questions as invitations to reflect on non-healthrelated losses only. This possibility suggests an avenue for future research, such as a study that asks therapists to consider all health and non-health-related losses that impacted them and their therapeutic work. Stroebe and Schut's (1999) grief theory may partially explain the experiences of the participants most affected by lost in-person therapeutic space. Some participants appreciated the pre-COVID, shared therapeutic space and in-person therapeutic dynamic as significant and intimate-a space marked for therapy where the client and therapist met. They referred to a particular kind of thinking and relating-distinct from ordinary life-that happens in this environment. Their responses reflected loss-oriented thinking typified by the bereaved person imagined in Stroebe and Schut's (1999) dual process theory. Like that person, even the participant who dearly missed in-person counseling could engage with restoration-oriented activities (that is, those who engaged with and adjusted to life now), even if they were seen as necessary and somewhat unwelcome requirements of continuing to work. In contrast, therapists who appeared to mourn the loss of in-person space appeared less likely to see the opportunities in the remote counseling environment. These participants' views align more with some commentators' (e.g., Kashyap, Chandur, & Reddy, 2020) view of remote counseling during COVID-19 as potentially effective. In fact, Kashyap, Chandur, and Reddy (2020) view remote counseling as potentially offering what the most concerned among this study's participants feared lost-that is, stability, consistency, and a "secure base." As Yalom (2001) noted about self-care: "Too often, we [therapists] neglect our personal relationships. Our work becomes our life" (p.252). The sheer number of actual and potential losses related to this pandemic have appeared to convince all to prioritize the self. Some linked loss with self-care explicitly, others implied as much by describing new habits (e.g., calling colleagues and walking daily) in response to losses of social contact and a life outside the home, for instance. The timing of this emphasis is interesting because self-care has long been known to be essential. It speaks to the shifted perspective in the shared trauma literature: life is reviewed and a changed perspective-in this case, in work and its relationship to self -is evident.
The losses, adjustments, and coping strategies described by the study participants showed that they understood themselves to be part of (not separate from) the world of their clients during this pandemic. Neither the shared trauma literature nor grief work positions this commonality as an unequivocal problem; rather, the potential benefits for a therapist from an insider's knowledge and experience of trauma are highlighted. In fact, some grief therapy protocols (e.g., Masterson et al. (2013) family-focused grief therapy) foster a sense of shared loss. They ensure that the therapist is introduced to the person who will be mourned and the relationships impacted before the person's death so that the bereaved can process their grief with an expert who knows. The participants' delineations indicate that they know they know (i.e.,i they know that they have "met" what their clients have lost) and are committed to attending to their own related feelings so that their clients will benefit optimally from their shared experiences.

Conclusion
Through the lens of shared loss, this preliminary study provides a snapshot of the COVID-19 pandemic's psychological impact on clinical social workers and their counseling work. The shared loss of space was central to the study's focus. Participants felt the loss of therapeutic space the most intensely and considered how to lessen its potentially disruptive and negative impact. Some participants alluded to the fact that remote counseling offered opportunities, as well as challenges, to therapeutic work. The negative predictions of other participants could be understood within a grief processing framework: the greater the felt loss, the greater the difficulty in adjusting to life post-loss.
Further research should be directed toward promoting a better understanding of the loss-related challenges in counseling and identifying potential solutions, such as remote counseling practices, self-care, and utilization of the home office space. Some participants in this study alluded to adaptations in their therapeutic practices that made remote counseling work well for them and their clients. In keeping with the literature on shared trauma and its recognition of the benefits to the therapist and therapy, future studies are needed to uncover the evolving face of remote counseling during this pandemic to unlock its potential to offer comparable, convenient, and (relatedly) improved therapeutic care. Have clinical social workers' attitudes toward remote counseling remained constant over the course of quarantine? What impact does a clinical social worker's COVID-19 illness have on therapy and its effectiveness? Answering these questions could help with further analyses of the new terrain of therapy implemented during COVID-19 and the reality of remote therapy during quarantine and beyond. Finally, this study uses 'shared loss' to describe losses during this pandemic that are impactful but not traumatic. It invites a theoretical discourse on this application, its differentiation from shared trauma, and the implications of its use to describe pandemic-related losses.
Funding There was no funding received for this research.

Declarations
Conflict of interest Author declare that they have no conflict of interest.
Ethical Approval This study was approved by New York University's Institution Review Board (IRB). Informed consent was attained from all participants that disclosed all possible risks and limits of confidentiality.