Returning to the office

I finally returned to my office after a year and a month. Or more accurately, since I was in my office all along making video calls, it’s some of my patients who returned.

Two weeks ago the CDC issued new guidelines: people vaccinated against COVID-19 can meet safely inside without masks. The guidelines appear aimed at social occasions like dinner parties, not psychiatric practices. But after reading them I no longer felt limited to offering virtual treatment.

The mechanics

To be clear, I am fully vaccinated, and this only applies to patients who are too. I continue to see the unvaccinated virtually. And for now at least, it’s voluntary. I don’t insist that anyone return to the office if they prefer video.

I developed standards: This is not for anyone who has a high-risk person in their family/pod. I run an exhaust fan in the office. I open the windows in the waiting room and bathroom. For new patients, I ask to see their vaccine card, and I show them mine.

I have rules: Do not come to the office if you feel sick. Don’t bring anyone along, e.g., to sit in the waiting room. Wear your mask in the building until we are in my office.

And then we meet without masks in the office. I don’t disinfect surfaces. It’s pretty much like 2019.

Issues I considered

Is it discriminatory to see only the vaccinated in person? I decided it’s okay. Vaccination status is not a protected class. I already discriminate against would-be patients who seek psychiatric services I’d rather not provide, and sometimes for other reasons. Presumably it’s stickier for a publicly funded mental health clinic; fortunately not my situation. I see no reason to deny the option to some, just because others can’t (yet) partake of it.

I also decided not to exclude vaccinated folks with riskier lifestyles. For example, those who work directly with COVID patients themselves, or who sometimes ignore social distancing rules. The CDC made no such distinctions in its guidelines. Also, I’d have to make difficult judgments of risk, not a role I want.

I ask patients to choose either video or in-person appointments, not to switch back and forth haphazardly without discussion. I consider this a “frame issue,” that is, part of the consistent structure of therapy that makes it safe to feel vulnerable. (Similar frame issues include keeping sessions the same length, not varying the fee, and not shocking the patient with sudden changes in the tone or setting of treatment.) I still invite a rare phone or video session for extenuating circumstances, as I did before the pandemic. And while it hasn’t happened yet, I’d permit a rare in-person session for a vaccinated person who usually meets with me remotely.

The future

I anticipate most of my existing patients will eventually return to in-person treatment, which I’ve always believed is superior to virtual alternatives. However, some can’t. During the pandemic I began seeing a few people who live very far away. It isn’t practical to meet in person. If for no other reason, my practice will indefinitely remain a mixture of in-person and virtual.

And some can return but won’t. A few vaccinated patients recently told me they prefer meeting by video even though they could, and in some cases formerly did, come to the office. As mentioned above, I haven’t insisted they make office appointments. I’m not sure I ever will. But their refusal confirms a concern I expressed almost exactly a year ago, that some will find the compromises made for the pandemic attractive, and they won’t want to give them up.

My thinking has lately evolved on this point. The problem is not that virtual convenience is inherently bad. Some people, e.g., busy single parents, might not pursue treatment at all without a virtual option. There are situations where virtual treatment is needed, and many more where it’s a sensible choice. What’s bad is ignoring the trade-offs.

At some level, I find it hard to believe that anyone seriously doubts the superiority of in-person psychiatric treatment or psychotherapy. Those who can come to the office without undue hardship enjoy the “full-bandwidth” experience: in 3-D, with nary a video lag or audio malfunction. Subtle nonverbal cues and transient facial expressions carry important meaning. There’s a “presence” lacking in mediated communication. It’s simply a more real human relationship.

Closing the virtual door

And that’s why I made my biggest decision: I’m not taking on any more virtual patients, vaccinated or not. Many individual clinicians, not to mention startups that aggregate therapists into rows of pretty headshots on their websites, already supply the video option. More of them pop up online every day. As in fine dining versus fast food, the discerning will value quality over convenience. Granted, there’s a time for convenience: a difficult individual circumstance here, a worldwide pandemic there. We’ve all had to live on convenience food, and convenience treatment, for the past year. Now it’s time, for those who can, to improve their diet.

Photo by Daniel Schludi on Unsplash

5 comments to Returning to the office

  • Eliza

    “… some will find the compromises made for the pandemic attractive, and they won’t want to give them up.” Exactly. Interesting read from your perspective. From my vantage point: I’ve been vaccinated for some time – though might classify as high risk from your description, yet still tested weekly and careful, thus good to hear the room for compromise (or acceptance). Nonetheless, for many reasons, I think virtual options (which took some getting used to) are far preferable to me. I’m not sure that either option is particularly convenient for the patient, but again, impossible to generalize. Wondering, though, if one approach always rises to the top as you suggest? Will be interesting to see how all of this sorts out in the coming year or two.

    • Hi Eliza,

      I didn’t mean to suggest that in-person always “rises to the top.” As I wrote, sometimes other factors take precedence. I also won’t be surprised to hear of instances where, other things being equal, virtual treatment simply works better for some folks. But I still maintain that as a general rule, in-person therapy is superior to the virtual versions. I agree, it will be interesting to see how all of this sorts out. Thanks for writing.

  • Anon

    Just curious, would you accept an immunocompromised patient, e.g., a kidney transplant who wanted to be virtual for now? They are looking into passive immunization strategies, but most don’t seem to respond to the vaccines all that well and have to behave as though they are unvaccinated.

    • Hi, thanks for writing. As I wrote, I’ve lately been turning away anyone who seeks virtual treatment. My rationale is that virtual treatment isn’t in short supply for those who seek it, or need it. But every rule has its exceptions. Perhaps in some special circumstance I’ll decide to see a new person virtually. It’s not my intention to be rigid — especially with myself! — only to practice in a way I both prefer and consider more effective.

  • Anon

    Thanks. I was just thinking about it, because my boss is a kidney transplant patient. Because of the nature of her research-protocol transplant, she was able to live for 20 years without immunosuppressants, but she had to start them last year just before the pandemic hit. Relaxing mask mandates in public until cases were down and vaccination rates up (not such an issue in SF) has felt like a huge slap in the face. She had no antibodies and is now less safe, because barely 50% of the population is fully vaccinated (2nd highest in the nation too) but more than 50% of the population will stop wearing masks come May 29. The message now is: you are in your own to protect yourself with an n95. I could imagine that not being accommodated under those circumstances would feel similar. Walensky’s comments felt like a punch in the gut to her. Navigating that new reality in the face of a return to normality for everyone else is going to be a challenge until they come up with better treatments/ prophylactics therapies for people in her situation.

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