Alisa Singer was raised in Edmonton, did her undergrad at the University of Alberta and completed her PhD in clinical psychology at the University of Calgary. She moved back to Edmonton in 2013, and opened her private clinic in 2014. We talked to her about what clinical psychologists do, how what they do has changed during the pandemic, and the kinds of problems she’s helped her clients with over the past few years.
Edited for length and clarity.
What does a clinical psychologist do?
Basically, we learn how to do research. And we learn how to understand research and how to implement research for our practice, what we call evidence-based treatment for mental-health disorders. We’re taught what’s called a scientist-practitioner model training. So what that means is, we learn the science of psychology. Typically, clinical psychologists do a lot of their training more in hospital settings. So we get exposed to a wide variety of people of all severities and many different diagnoses. We learn how to diagnose, assess and treat mental health. Our area of expertise is really in the formal assessment of mental disorders. We have assessment tools that we use to help clarify things. And then we do psychological therapy.
And how do people access psychological therapy?
What’s been happening thing in recent years is that psychologists have been moving more and more out of the public healthcare system for a variety of reasons. Now, seeing a psychologist has become a little bit like a luxury. People usually have to pay out of pocket, or they have insurance, but most insurance plans do not cover what people actually need in terms of therapy. The average person might need eight to 12 sessions, just on average, but some people’s benefit plans will only cover one or two.
A big point of our health crisis series is that it’s been happening for a while, and the pandemic has exacerbated it. Have you seen the same in your field?
Pre-pandemic, one in every five Canadians reported having some mental health problems. And a recent survey of 1,803 Canadian adults, done by Mental Health Research Canada, found that about 18 per cent of the sample reported anxiety or depression prior to the pandemic. And among this group, the number of people who reported worsening depression anxiety doubled. And in general, 20 per cent of the sample reported worsening anxiety since the pandemic. So what this tells me is that basically, it was 20 per cent before the pandemic, and it’s 20 per cent now, but it’s more severe. It’s worsening because of the pandemic.
So the numbers aren’t increasing, but the intensity is?
Yes. For me, clinically, I had a steady stream of clients and a waitlist within a few months of opening my private practice in 2014. But what I’m noticing is that people tend to stay longer than that average of eight to 12 sessions. Now it’s way higher. I’m seeing people for 20 to 30 sessions on average. So people are coming for longer periods of time. I find that we’ll make progress, you know, or start to feel better. But then we get another variant, or more lockdowns, and that will exacerbate things all over again.
Does anything differentiate the clients you are seeing now?
There’s a group of people who want to talk about COVID and how to cope with it. I am helping them try to navigate the uncertainty of the pandemic, and the social isolation that has resulted because of that. And we know from psychological research that social isolation is not good. It does lead to both physical and mental health problems.
And then there’s another group of people who had pre-existing problems — they might have had panic disorder, or they had social phobias, or depression, before — and now, all of a sudden, this pandemic has shone a light on what they were struggling with. They had more time on their hands, they’re at home more, and they start to realize: This is something I need to address, I don’t want to live like this anymore. It’s been everything from a fear of heights, to obsessive compulsive disorder and post-traumatic stress disorder. So actually, some of the things I’ve been helping people with aren’t even related to the pandemic, but the pandemic has brought them to me.
How do you deal with someone who is dealing with COVID-specific isolation?
It’s certainly been a challenge, and we’re all living a shared life experience right now. So as therapists we’re going through many of the same things that our clients are going through. So we’re coming up with innovative ways to challenge social isolation, like going for a walk with a friend. I’ve been encouraging my clients to find some of the secret little gems in Edmonton, and there are some pretty amazing things that I’ve never experienced — all of a sudden, I have found cross-country skiing.
One of the other things we know from the research is that behavioural activation is among the most important treatments for depression. Basically, what that means is doing things — both pleasures and things that you need to do — by scheduling them, even though you don’t feel like it. Because we know that motivation comes after, not before.
For some people, was having to stay home a kind of relief? Have there been silver linings, for some clients, or would you not frame it like that?
At the beginning of COVID, when we were all told to stay home, people who were prone to anxiety were almost happy with it. Because they didn’t have to face the risk. It was pretty straightforward: Stay home and your risk is low. So my clients who have obsessive compulsive disorder, we were almost living in their perfect dreamworld, in some ways, because they got to just stay home. But then as things opened up, that’s when anxiety has gone up. Because it’s like, now I have to make a decision. Do I send my kids to school? Do I go to these activities? Is this safe? And that’s been very challenging.
But, in general, I talk all the time with clients about what are the silver linings. I think yes, we do need to think about what have been the positives, and to really try to hone in on them.
I imagine someone with agoraphobia would have gone through the same thing.
A really good example. So agoraphobia is the fear of leaving the house, because you’re afraid you’re going to have a panic attack. And what people do is they avoid leaving the house to try to feel safer. So yes, in the beginning, when we were told to stay home, it would have temporarily alleviated some of those symptoms. But, you know, as soon as you need to start going back out again, yes, it’s worse.
It’s a short-term way to manage your anxiety. But, in the bigger picture, you’re making it worse, because you’ve developed a fear in your mind. Your brain has made a connection that going out means danger. And then, when you stay home, that connection gets stronger and stronger. So to unlearn that connection, you have to have experiences where you go out of the house and you learn something new, you learn that going out equals safe. And we do that over and over — a little farther each time, even just to the end of the block — in order to beat out the old connection that going out equals danger. And then eventually, with more and more learning, you start to change the way you think.
How has your profession adjusted to COVID, in terms of how you treat clients?
I often joke that there’s nothing on my bookshelf about pandemic psychology. There’s very little out there. But our professional organizations and associations have been readily giving out information to us to help stay up to date, and we have platforms and ways to consult with other psychologists when needed. And we can access, in the last year or so, more and more research on the impact of the pandemic on mental health, conducted surveys and things like that, to help us to understand.
But we can come up with innovative ways to do the things that we’ve always known can help mental-health problems, because they still apply in these circumstances. So for example, challenging people’s thoughts is a very important treatment for depression, and so is challenging their behaviour. Like I said before, scheduling things. That’s therapy we’ve long known helps with depression, and it still applies even in this circumstance.
In terms of anxiety, we know that anxiety is a future-oriented feeling — you’re afraid of something that’s going to happen in the future. One of the things we’ve known for a long time is that people who have something called a low tolerance of uncertainty are more prone to anxiety. So what does that mean? People who want to feel certain, they can’t tolerate uncertainty. And uncertainty is a huge part of this pandemic — when is it going to end? Am I going to get sick? Am I going to pass it on to loved ones? How am I going to work? Helping people navigate those risk assessments is something that we know how to do.
So in those cases it’s a matter of doubling down on strategies you already know.
Yes. And one of the things I’ve been teaching my clients is that the people who are going to be the most adaptable during this are people who can be fluid in their thought processes and their behaviours. Because there’s been times when the risk is lower, and then there are times where it’s higher. So decisions we make now might be different than the decisions we would make at the bottom of a wave. I’ve been trying to encourage my clients to think as flexibly as they can. I ask them to ask themselves: Is the risk of COVID worth doing this activity? For some people, the answer is yes, whether it’s going to the grocery store, or allowing their children to go to school.
What about the other end, people who are over analytical about their day-to-day decisions?
Right, so people who are obsessive compulsive tend to over read the news, and search Google too much. So yes, one of the things I’ve been encouraging people is to limit their consumption of information.
Is it incorrect to think most of your job is telling people what to do? It sounds like you ask questions more than prescribe instructions.
So my area of expertise is something called cognitive behavioural therapy. Cognitive behavioural therapy is an empirically supported treatment for depression and anxiety, and been studied for many years. It is a well-defined therapy, and the research shows that it is effective psychological treatment. And so there are two parts to it. One is challenging people’s thoughts about something. And the second is challenging their behaviour. So when I’m talking to a client, of course, I’ll sometimes give advice on what to do. But I mostly do try to just ask questions. It’s called Socratic Questions, to help them to come to the conclusion themselves — asking them questions to help them challenge their negative thinking.
Going on three years, have there been any surprises, compared to your expectations at the beginning?
At the beginning, because I’m in a private practice, and people pay out of their own pocket, my initial fear was that I wasn’t going to have clients because people would be losing jobs and adjusting their finances. I thought I would actually see a decrease in my client list. But that’s certainly not the case at all. I’ve been busier than I’ve ever been in my life. I’m seeing more people per week than I ever have before.
I was also stuck at home, so I thought, Well, my phone’s ringing off the hook — I might as well add a few more people. I’ve always had a steady stream of clients, but I’ve allowed for a few more extra clients to manage the demand.
I think another surprise is that even despite everything that’s going on, I have seen people overcome their fears. And I’ve seen people get better, even though they’re living in trying times.
It’s not always a full recovery. But they’re coping better. You know, as human beings, we are resilient, and we are adaptable. And even though we are being faced with a world crisis, I think people are people are adapting. And so that’s great. And for people who had pre-existing problems, I have seen them get better. And that’s been very rewarding as a therapist and very inspiring as a human being. We can work on ourselves, and we can change things in ourselves, even during these times.
Many of the people we talked to in our “Crisis” series brought up the provincial government’s actions, or lack thereof, as contributing to health care problems. How has your field been affected?
One thing is just the fact that psychological treatment is not covered by Alberta Health, which was the case pre-pandemic as well. There have been some appeals to the government to reconsider that, but I imagine that even if that change were to happen, it might not even happen in my life time. But I would love to see the government allow every Albertan to have access to, let’s say, five sessions with a registered psychologist.
Is that arguably the toughest part of your job, knowing that you and your colleagues can’t help all the people who need it?
Oh for sure. And it happens for many reasons. Sometimes it’s financial, sometimes people are simply too busy. I mean, I have a waiting list right now, and it’s hard. But you just help one person at a time and focus on who’s in front of you. Otherwise you burn out pretty quick.
How do you avoid burn out?
I try to practice what I preach, you know? Like I said, I’ve been trying to embrace life in Edmonton, finding new things that I never did before. And that’s been actually kind of fun and exciting. I tell my clients: Find the things that you can control and control the crap out of them (laughs). You can control what you do day to day, how you spend your time, what you ingest in your body. So I try to do that for myself and focus on the relationships that I have, and the things that I’m capable of doing. And that’s helped me kind of get through.
You can reach Dr. Alisa Singer at her website.
And if you are feeling the strain, it’s important to know you are not alone. Help is out there. Alberta Health Services’ mental-help line is available 24/7, at 1-877-303-2642. The addiction help line number is 1-866-332-2322. When it all becomes too much, the bravest thing you can do is ask for help. Please, do not suffer in silence.