After thirty years of conducting therapy sessions in the public sector of the addiction and mental health fields as well as in private practice, an unforeseen pandemic hit. Lockdown measures ensued. This unfortunate trajectory led to nine months of paying for unused commercial office space in Manhattan’s Times Square. It was simply financially untenable to keep holding on for that ambiguous day when normalcy would resume. So I closed my doors.
It’s been over a year now since being catapulted into conducting trauma therapy sessions from my home. The rapid influx of referrals quickly maxed out my practice, making it necessary to establish a waiting list and a list of clinicians with availability. In fact, The Washington Post reported that one month into the COVID-19 pandemic, texts to federal government mental health hotlines increased by about 1,000%.
Ensconced in front of my computer for hours at a time, five days/week my clients and I video conference their struggles and aspirations, traumatic wounds, fears, and loneliness. We laugh, we cry, we speculate and complain about our sedentary lives and our aching backs. We marvel over the dystopian landscape we find ourselves in.
Before life as we knew it took a radical turn, as a practitioner of psychodynamic therapy, (as opposed to cognitive behaviorism /CBT) I was pre-disposed to viewing tele-health as sterile and deficient. I thought of phone sessions and video conferencing as an occasional adjunctive to in-person care. It was a convenient and beneficial option, but not as an adequate modality unto itself. After all, unlike the practical skill based application of CBT, the foundation of psychodynamic work is the bond between the therapist and the client.
In psychodynamic treatment, the therapeutic alliance serves as an attachment template, which allows early life attachments and relationships to be consciously processed.
This collaboration is the driving force that sustains and supports a courageous embodied process of intra-psychic exploration and healing. Deep excavation of one’s history and the unearthing of unconsciously repressed material and the assimilation of powerful emotions, is characteristic of psychodynamic work. This profound long-term practice of self-exploration allows one to fully comprehend one’s defensive posturing and patterns of behavior so that real intrinsic shifts can occur.
It’s difficult for many individuals to take a deep dive into their emotional world, especially a world rife with traumatic abuse, but psychodynamic therapy guides clients in doing so. Suffice it to say, I had huge concerns with the efficacy of providing quality care to folks beset by complex trauma, through video platforms.
To my surprise, in spite of my concerns and treatment orientation, tele-health has proven to be a viable substitute. I still maintain that cultivating a healing client-therapist collaboration characterized by love and trust requires effort and direct face-to-face contact, but I am witnessing the attainment of therapeutic goals through remote therapy. Furthermore, research does indicate that online therapy is a credible vehicle for treating anxiety, depression, and trauma.
Yet even with positive results, I remain on the fence as to whether a pixelated holding environment can conclusively offer the same sort of abiding intimate support that face-to-face interaction provides. It is too soon to know what the long-term impact will be. Furthermore, although tele-health has been around for decades, many clinicians are still unsure about the clinical, ethical, and legal issues that emerge as distance therapy becomes a more accepted practice.
With nearly one in five Americans presenting with a diagnosable mental illness, the phasing out of in-person therapeutic engagement raises serious issues with long-term efficacy and desired outcomes, especially when treating children and folks presenting with relational trauma and serious addictive disorders. Perhaps it’s for this primary reason, along with mass vaccination, the warmer weather and some planned excursions that I’m revisiting the possibility of returning to in-person sessions at least once/week.
It seems some of my clients concur, albeit there may not be enough collective interest to constitute subletting a space. Alas, despite being tired of groundhog day, for better or worse we have adapted. The once ordinary and arduous trekking out to meet in person has now become a gratifying indulgence that new established stay-at-home routines may not accommodate. Scheduling a therapy appointment that entails travel is becoming increasingly implausible as we acclimate to a remote lifestyle.
Although it may not seem germane, in NYC riding the MTA is fraught with anxiety due to the escalating crime. Hence, the deterioration in basic municipal services is indeed a relevant factor in determining scheduling outside of safe parameters.
Of even greater concern for clinicians and therapy clients are the mutant variants of the coronavirus coming down the pike. This looming threat is creating trepidation with committing to direct personal contact. Evidently, the temporary relaxing of sheltering in place measures has not ensured that the storm has lifted.
In sum, the findings from a study regarding factors associated with the decision to provide in-person therapy in the age of COVID-19, conducted by Liat Shklarski, Allison Abrams, and Elana Bakst (J Contemp Psychother (2021)), showed that for most therapists a blend of in-person and remote work would be the ideal approach to take in the future. From my observations it does seem that an irreversible cultural shift has occurred with remote communication, suggesting that the role of telecommunications in the work and health sectors is here to stay.
Consequently, the impact of tele-health in a post-pandemic world will mean a new regulatory path that addresses licensure, privacy and therapeutic trends. While this may be to my advantage when I relocate to Montreal next year, I am hoping that my clients will be amenable to traversing the process of closure in person. Only time will tell.