Covid and IFS therapy

Internal Family Systems Therapy is a rapidly growing approach

that offers real hope over the mental health fallout

from Covid, writes psychotherapist Gayle Williamson

IMAGINE you are one of the many thousands around the world who have suddenly found themselves in a Covid ward, fighting for their lives. Imagine you’ve been placed face down in the prone position to increase your oxygen levels for many hours a day as part of your treatment. Imagine how scary, uncomfortable and disorientating that would be. 

Afterwards, you’d likely just want to put it behind you and try and forget it even happened. It’s what I think a lot of us do when we experience something overwhelming –  once it’s over, we try not to think about it. I think we do that because we believe there’s nothing to be done about it, that we can’t change it. The only trouble is that locking it away only works some of the time; the rest of the time there are likely to be scary flashbacks, nightmares and an ever-present underlying anxiety.

There’s already been a lot of research in the past year into Covid infection and trauma, found not only among those hospitalised with the disease but also among the health-care staff looking after them. One UK study of more than 13,000 Covid patients earlier this year found that one in 

three who were ventilated experienced symptoms of trauma. In the same study, one in five experienced extensive trauma symptoms even without having been ventilated. This was backed up by an Italian study that suggested one-third of Covid survivors may have been traumatised. Particular predictors of trauma were if you experienced persistent breathlessness or delirium. Many in-patients have become delirious as a result of experiencing a lack of control over their bodies, restrained by catheters, being disorientated by medication and continually changing staff in full PPE. Never mind the fact that if you’re in hospital, you know your illness is severe – so inevitably there’s a fear of death.

So there’s a clear and urgent need here to provide effective mental health intervention.

Case history

The traumatic after-effects of Covid hospitalisation and what can be done about it have been coming to my mind in connection with my work with a remarkable woman, who in recent years underwent major surgeries for not one but two aggressive cancers – one tumour was found in her breast which necessitated a mastectomy, and another was later found in her lung. The second tumour developed very quickly, so that just 18 months after removal of the first tumour Nicky (not her real name) was admitted for another surgery.

I had first seen Nicky more than five years ago when she lost her husband in a car accident, leaving her a single parent to three young children. She was in a good place when I last saw her, so it was a shock to learn the reason why when she called asking to meet for a session. We talked over Zoom because less than a month before, she had had the mastectomy. Serious illness and traumatic surgery plus loss and grief equals considerable emotional overwhelm.

There are several kinds of trauma therapies and all will be helpful to varying degrees in helping Covid survivors deal with what has happened to them. The approach I use is the rapidly growing Internal Family Systems model – which asserts that we’re not a single ‘I’, but rather that we all have multiple personalities or ‘parts’. So when I heard what Nicky had been through, I knew immediately that there would be parts of her psyche triggered by, or still stuck in, the hospital experiences (what we call ‘exiles’); and other parts of her (‘protectors’) that would be desperately trying to manage the intense feelings of Nicky’s exiles. I knew that any sense of her 42-year-old core Self – the seat of consciousness and a source of healing wisdom and strength – would be being hijacked by all these parts.

Challenging experiences will typically trigger younger parts of us activated by similarities in the current experience, and so it proved with Nicky. Just after her successful first surgery, she was struggling to function – paralysed by fear that all the cancer hadn’t been caught and that she’d leave her children without their remaining parent. Other approaches might teach clients to avoid the worry and focus on something else, such as their breathing. But in IFS, you know that this ultimately only forces the part of you that’s in distress to shout louder for your attention. So instead, IFS has you focus inside yourself on the worry and talk to it – and the amazing thing is that it will talk back, in words or images. The voices we all hear in our heads are not random thoughts but are actually real inner personalities of varying age with their own feelings, thoughts and memories, who are stuck in our unconscious in difficult situations in the past. It’s why you can be in your 80s but still regularly feel exactly as you did when you were, for example, eight years old and being bullied at school. 

When I first got Nicky to focus inside herself, she was surprised to discover, not a part of her stuck in the surgery trauma as you might expect, but a 12-year-old part of herself still worrying that her mum would die. Nicky’s mum had breast cancer herself at this time and was seriously ill for many months. So the part helped Nicky  understand that her fear of dying was both a current and past reality. She was able to listen to and acknowledge all the girl’s fears and then tell her that her mum has gone on to live a happy life and to even show her pictures from a party they’d had, just before the pandemic hit, to celebrate her mum’s 70th birthday. We helped the part then to let go of her fear – leaving Nicky feeling, crucially, more able to cope in her current situation.

Just 18 months later, however, Nicky developed new symptoms and the second tumour was found. After another gruelling surgery during which a lobe of her lung was removed, we met another of her key parts linked to her fears around dying. Nicky had been waking up every night without fail at 3am, unable to go back to sleep, which of course left her exhausted during the day and grumpy with her children. So we went inside and found a very tired, hypervigilant protector part that said it was trying to keep her alive. It thought she was still only eight – a time when her parents were still living together but were on the point of a very fractious divorce. The eight-year-old Nicky was terrified about being abandoned by either or both her parents after hearing their many shouted threats to leave. She recalled often listening anxiously at her bedroom door to make sure her parents went to bed and if she woke in the night she’d creep to their room to make sure they were still there. Essentially, the primal fear would have been, ‘how will I survive if my parents leave me … I’ll die’. So this part was still doing this, still keeping watch on behalf of the eight-year-old, not realising that Nicky had survived her childhood and was now in a different context. 

Hope and healing

More recently, having helped parts like this relax and healing the younger parts of her who were compounding her current distress – just as Covid survivors can be sure that whatever they are experiencing now will be being exacerbated by their own past traumas – Nicky has been able to tackle the trauma of her surgeries. For the past few sessions, she’s connected internally with the part of her holding all the distress of the hospital experiences. She’s been able to go in and witness with compassion and courage everything that happened – from enduring days after the surgeries unable to wash and periods of extreme pain, to the severe discomfort of various drains and horrible side-effects from medications. She’s provided what was missing for the part at the time – sometimes just a hug, other times brushing her hair, or just reassurance that she will actually survive it all.

 We’re not there yet, but I know we will get to a point very soon where the part feels healed, and Nicky will be able to be fully present in her life again.  And that’s what Covid survivors can do for themselves too, so that they don’t have to live with the legacy of their trauma. Because no matter what you have been through, there is a core you who has not been broken and damaged, who is inherently strong and calm and who knows how to heal your traumatised parts. Yes the past can’t be undone, but how you experience the past emotionally can – and that makes all the difference.

*The case example cited is a fictitious amalgamation of several client cases in order to protect identity 

Gayle Williamson (MIACP) is an IFS psychotherapist and consultant in private practice in Dublin. www.ferneytherapy.ie