COVID-19 risk tolerance and therapy

I’m increasingly asked by patients and potential patients when I plan to see people in the office again. I had been an exclusively “in person” psychiatrist and psychotherapist until mid-March of this year, when the pandemic forced even skeptics like me to convert completely to remote (“virtual”) treatment. Like many of my colleagues, over the past three months I’ve made an uneasy peace with phone and video sessions, and all the accompanying rigmarole. Although I can work with it, it’s far from ideal. I look forward to dispensing with the earbuds and glitchy bandwidth and resuming my prior practice.

While some folks hope I’ll see them in the office right now, others fear I’ll “force” them back before it feels safe. I assure them I won’t. Even when the office reopens, I anticipate a hybrid situation for months to come, a combination of office and online appointments. Normality is a long way off.

After all, risk tolerance varies. Some of my fellow San Franciscans now share walks outside without masks — nominally six feet apart, but not always — and some are again dining in outdoor cafes. Others are not. Even leaving aside political theater and virtue signaling, reasonable people can disagree about what feels safe.

While it would be comforting to ascribe differing risk tolerance solely to logic and the biologic, e.g. older people are at higher risk, it is far more subjective than that. Partly it’s self-image: are we proud of being sensible and prudent, or fearless and no-nonsense? Are we the type to cite scientific studies, or our gut? Do we sacrifice on behalf of others, or believe only bleeding-hearts do that? Partly it’s modeling by others, variously called peer pressure or social learning theory. If everyone nearby wears a mask, we’re more comfortable wearing one; if others reopen their therapy offices, we’re more apt to reopen ours.

The arbitrary way most of us make these safe/unsafe determinations also reflects wishful thinking and confirmation bias, cognitive tricks we play on ourselves to rationalize unsafe behavior — or conversely to scare ourselves when the situation isn’t that bad. “COVID-sorting” is essentially the use of prejudice and stereotypes to make safety assessments. We’re loath to see our own decision-making in such unflattering light, but of course we readily see irrationality in the fools who decide otherwise.

I’ve been in online discussions with mental health professionals across the country. Some are actively strategizing how to medically screen patients at office entrances, how to disinfect surfaces between patient appointments, how to conduct sessions while masked. Others sound pessimistic about ever going back to the office. I imagine this variation isn’t unique to my field. It was far easier to hunker down uniformly a couple months ago than to customize a re-emergence now.

Adding to the challenges faced by many businesses are special considerations for therapy practices, where feeling safe is crucial. Psychotherapy can only happen when words can be said and reflected upon without harmful real-life consequences. It exists in name only if either party fears a potentially fatal illness in the encounter. Indeed, it’s the therapist’s duty to assure safety in treatment, which is why our ethics forbids sexual and other forms of exploitation. The same rationale obliges therapists to take reasonable steps to assure the safety of both parties from viral and other medical threats.

And if that weren’t enough, these practical matters pale in comparison to the realm of fantasy, where under normal conditions patients may imagine the therapist to be benevolent or evil, soothing or toxic, and themselves impervious or vulnerable, lovable or repulsive. When explored as transference fantasy, these reactions can lead to insight and change. However, when toxicity and vulnerability stem from actual health risks, their value as guideposts to the unconscious is lost.

Ultimately, my answer regarding reopening the office hinges on inertia — my willingness to take the necessary steps — and practicalities, not unconscious fantasies. Will doing so necessitate calling patients the night before to screen for illness? Checking their temperature at the sidewalk entrance, one floor down? Supplying hand sanitizer and spare masks, posting signs, cleaning chairs and other surfaces between appointments, keeping office air flowing with fans and open windows?

Is this rigmarole preferable to the rigmarole of online intake forms, frozen video feeds, garbled audio, and occasionally needing to switch to the phone halfway through a session? It’s hard to choose between two bad options. And even if I decide “in-person” is preferable, will many of my patients concur? While it was my decision to exclude them from my office in March, it will not be my decision alone to readmit them.

Deciding when to reopen a therapy office isn’t only a question of risk tolerance. It’s balancing risk against expected benefit — two subjective estimates — and weighing competing rigmaroles. Even as a fairly risk-tolerant person, I am not ready to reopen my office just yet. By my estimate, the calculus still favors waiting to reopen another day. I only hope that, somehow, that day comes soon.

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