However good it may feel, there’s always danger when wishing something were true gets in the way of rationally balancing of risks and rewards. This is especially true for wishing mid-pandemic in-person work were a return to normal. There is a specific and imminent danger that regulators and insurance companies will ignore the harsh realities of the Covid-19 pandemic by prematurely terminating emergency waivers for telehealth. You may be forced to do something you do not want to do, either pay out-of-pocket or work in-person when you do not feel it safe or worthwhile to do so. We have to find the courage to engage the harsh realities of the pandemic however desperately one might wish things to be otherwise, and despite how some political leaders despicably try to pretend otherwise.
Let’s start with the reward side of the equation. Mid-pandemic in-person psychotherapy won’t be the same. The main problem is that necessary procedures for viral safety inevitably undermines fundamental experiences of psychological safety so necessary for effective psychotherapy. Like two people tethered together to keep each other safe while scaling a cliff, the experience of mid-pandemic in-person psychotherapy will be replete with dangers requiring constant vigilance and inter-dependence.
Psychotherapy is built on a promise; you bring your suffering to this private place and I will work with you to keep you safe and help you heal. That promise is changed by necessary viral precautions. First, the possibility of contact tracing weakens the promise of confidentiality. I promise to keep this private changes to a promise to keep it private unless someone gets sick and I need to contact the local health department.
Even more powerful is the fact that a mid-pandemic in-person psychotherapy promise has to include all the ways we will protect each other from very real dangers, hardly the experience of psychological safety. There will even be a promise to pretend we are safe together even when we are doing so many things to remind us we are each the source of a potentially life-altering infection.
When I imagine how my caseload would react were I to begin mid-pandemic in-person work, like I did for a recent webinar for the NYS Psychological Association, I anticipate as many people welcoming the chance to work together on a shared project of viral safety as I do imagining those who would feel devastated or burdened. But even for the first group of willing co-participants, it is important to see that such a joint project of mutual safety is not psychotherapy. No anticipated reaction included the experience of psychological safety on which effective psychotherapy rests.
Rather than feeling safe enough to address the private and dark, patients/clients will each in their own way labor under the burden of keeping themselves, their families, their therapist, other patients, and office staff safe. The vigilance required to remain safe will inevitably reduce the therapeutic benefits one might hope would develop from being back in the office.
As should be clear, mid-pandemic in-person psychotherapy unavoidably increases risks of viral infection for both patients/clients and therapists. There is a growing consensus, as reported in the Wall Street Journal, that “the major culprit is close-up, person-to-person interactions for extended periods.” That is pretty much an accurate description of an in-person psychotherapy session. We meet inside for extended periods of time in relatively close quarters.
Even the best in-office mitigation strategies, by design and definition, can only mitigate risk. As my colleague Dr. Jeffrey Taxman, a psychiatrist/psychoanalyst with a speciality in mass community trauma, wrote in an email, “Unlike emergency physicians, we cannot have true fit-tested PPE while doing therapy.” In addition to the painfully obvious human costs of additional infections, he usefully emphasizes that mid-pandemic in-person psychotherapy imposes risks on the mental healthcare delivery system itself. He writes that “after months of job loss, quarantine, and rising stress and community violence, there is a greater need than ever for access to psychotherapy.” Now is when psychotherapists are most needed. In this context the last thing one should do is risk depleting the amount of available psychotherapy through fear or avoidable illness and death.
The possibility of psychological risks in mid-pandemic in-person psychotherapy also needs to be considered. Will someone stop needed treatment because they feel the office is too dangerous, or maybe the trip to and from the office is a problem? Will some see the risks being taken and use that to trash the gains from three months of emergency telehealth? Will the anxiety of change increase substance abuse? We know that many mental health issues have physical co-morbidities that make people significantly more vulnerable to being ravaged by Covid-19. Will they stop needed treatment if emergency teleheath waivers are eliminated? And to name just one more from a list of possible risks, there’s the additional stress and tension among the most emotionally vulnerable who will have to decide whether or not to continue risky care.
No one should feel regulatory or insurance reimbursement pressure to take on these additional risks to provide or access psychotherapeutic care. Reason dictates that emergency waivers on telehealth restrictions should continue as long as the pandemic rages. While the virus makes the future even more uncertain than it usually is, the reduced clinical rewards and increased risks does make one thing clear: the only reason an insurance company would end emergency telehealth waivers would be a cynical attempt to reduce utilization by making psychotherapeutic care virally risky and less useful so that fewer people would access the care they need.
Let’s hope that doesn’t happen.
Todd Essig – Forbes forbes.com